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MODERN  SURGERY 


General  and  Operative 


BY 

JOHN  CHALMERS  DaCOSTA,  M.D, 

Professor  of  the  Principles  of   Surgery  and  of  Clinical  Surgery,  Jefferson  Medical  College, 

Philadelphia ;    Surgeon  to  the  Philadelphia  Hospital  and  to 

St.  Joseph's  Hospital,  Philadelphia 


Mitb  493  HUustratious 


THIRD  EDITION,  REVISED  AND  ENLARGED 


PHILADELPHIA   AND   LONDON 

W.   B.   SAUNDERS   &  COMPANY 
1900 


Copyright,  1900,  by 
W.  B.  SAUNDERS   &  COMPANY. 


EUEOTROTYPED  BY 
WESTOOTT  &  THOMSON.   PHILADA. 


PRESS  OF 

W,    B.    SAUNDERS  t  COMPANY. 


THIS   VOLUME   IS 
DEDICATED,    WITH    AFFECTIONATE    REGARD,    TO 

DR.  ORVILLE    HORWITZ, 

THE   FELLOW-STUDENT,   THE   HOSPITAL  ASSOCIATE,   AND 
THE   TRUSTED    FRIEND    OF 

THE  AUTHOR. 


PREFACE  TO  THE  THIRD  EDITION. 


In  the  preparation  of  the  third  edition  of  tliis  work  it  has 
been  found  necessary  to  add  considerable  new  matter.  This 
necessity  arises  from  a  consideration  of  just  criticisms,  from 
an  enlarged  experience  in  teaching,  and  because  there  have 
been  important  additions  to  surgical  science.  The  original 
plan  of  the  work,  however,  has  not  been  departed  from. 

1629  Locust  Street, 
Philadelphia,  September,  igoo. 


PREFACE. 


The  aim  of  this  Manual  is  to  present  in  clear  terms 
and  in  concise  form  the  fundamental  principles,  the  chief 
operations,  and  the  accepted  methods  of  modern  surgery. 
The  work  seeks  to  stand  between  the  complete  but  cumbrous 
text-book  and  the  incomplete  but  concentrated  compend. 

Obsolete  and  unessential  methods  have  been  excluded  in 
favor  of  the  living  and  the  essential.  There  has  been  no 
attempt  to  exploit  fanciful  theories  nor  to  defend  unprovable 
hypotheses,  but  rather  the  effort  has  been  to  present  the  sub- 
ject in  a  form  useful  alike  to  the  student  and  to  the  busy 
practitioner. 

The  opening  chapter  is  devoted  to  Bacteriology  because 
the  author  profoundly  believes  that  without  some  knowledge 
of  the  vital  principles  of  this  branch  of  science  the  vast  im- 
portance of  its  truths  will  be  ill-appreciated,  and  there  will 
be  inevitable  failure  in  the  application  of  aseptic  and  anti- 
septic methods. 

Ophthalmology,  gynecology,  rhinology,  otology,  and  lar- 
yngology have  not  been  considered,  because  of  the  obvious 
fact  that  in  the  advanced  state  of  specialized  science  only  the 
specialist  is  competent  to  write  upon  each  of  these  branches. 

In  Orthopedic  Surgery  are  discussed  those  conditions 
which  must  in  the  very  nature  of  things  often  be  cared  for 
by  the  surgeon  or  the  general  practitioner  (such  as  hip-joint 
disease,  club-foot.  Pott's  disease  of  the  spine,  flat-foot,  etc.). 
The  limited  space  at  command  precluded  the  introduction  of 
a  special  division  on  diseases  of  the  female  breast.  A  large 
amount  of  space  has  been  devoted  to  Fractures  and  Dis- 
locations, the  enormous  practical  importance  of  these  sub- 
jects calling  for  their  full  discussion.  Operative  Surgery  is 
considered  in  separate  sections,  the  most  important  pro- 
cedures being  fully  described,  giving  also  the  instruments 
necessary,  and  the  positions  assumed  by  patient  and  operator. 

11 


12  PREFACE. 

This  method  has  been  adopted  to  fit  the  work  for  use  in  sur- 
gical laboratories. 

Many  systems,  manuals,  monographs,  lectures,  and  journal 
articles  have  been  consulted,  and  credit  has  been  given  in 
the  text  for  statements  and  quotations.  Special  acknowl- 
edgment is  due  to  the  Amer'ican  Text-Book  of  Siirgery, 
edited  by  Keen  and  White ;  to  the  surgical  works  of 
Ashhurst,  Agnew,  the  elder  Gross,  Duplay  and  Reclus, 
Esmarch,  Albert,  Koenig,  Wyeth,  and  Bryant ;  to  the  Man- 
ual of  Surgery  edited  by  Treves  ;  to  the  International  En- 
cyclopcEciia  of  Surgery  edited  by  Ashhurst;  to  the  Siirgical 
Pathology  of  Billroth  and  of  Bovvlby  ;  to  the  Diagnosis  of  A. 
Pearce  Gould  ;  to  the  Surgical  Dictionary  of  Heath  ;  to  the 
Rest  and  Pain  of  Hilton  ;  to  the  works  on  operative  sur- 
gery of  Barker,  Jacobson,  Treves,  Stephen  Smith,  and  Joseph 
Bell ;  to  the  Minor  Siirgery  of  Wharton ;  to  the  dictionary 
of  Foster  and  of  Gould  ;  to  the  Principles  of  Surgery  of  Senn ; 
to  the  orthopedic  writings  of  Sayre  ;  to  the  work  on  Diseases 
of  the  Male  Geiierative  Organs  of  Jacobson ;  to  the  System 
of  Genito-iirinary  Diseases  edited  by  Morrow ;  and  to  the 
treatises  on  Fractures  and  Dislocations  of  Sir  Astley  Cooper, 
Malgaigne,  Hamilton,  Stimson,  and  T.  Pickering  Pick. 

The  Author  returns  his  thanks  to  the  numerous  writers 
vi^ho  courteously  authorized  the  reproduction  of  special 
illustrations,  and  particularly  to  Professors  Keen  and  White 
for  their  free  permission  to  draw  upon  the  American  Text- 
Book  of  Surgery,  from  which  a  number  of  pictures  have  been 
taken,  distinctively  those  referring  to  Bandaging;  to  Mr. 
John  Vansant  for  the  great  amount  of  labor  so  ably  and 
cheerfully  performed ;  and  to  Dr.  Howard  Dehoney  for 
the  preparation  of  the  Index. 

2050  Locust  Street,  Philadelphia, 
October,  1894. 


CONTENTS. 


PAGE 

I.  Bacteriology i? 

II.  Asepsis  and  Antisepsis •  45 

III.  Inflammation 60 

IV.  Repair 105 

V.  Surgical  Fevers "S 

VI.  Suppuration  and  Abscess 118 

VII.  Ulceration  and  Fistula 140 

VIII.  Mortification  or  Gangrene 150 

IX.  Thrombosis  and  Embolism 167 

X.  Septicemia  and  Pyemia i73 

XL  Erysipelas  (St.  Anthony's  Fire) 179 

XII.  Tetanus  or  Lockjaw 184 

XIII.  Tuberculosis  and  Scrofula 190 

XIV.  Rickets 200 

XV.  Contusions  and  Wounds 203 

XVI.  Syphilis      237 

XVII.  Tumors,  or  Morbid  Growths 264 

XVIII.  Diseases  and  Injuries  of  the  Heart  and  Vessels    ...  302 

1.  Hemorrhage  or  Loss  of  Blood 3~^ 

2.  Operations  on  the  Vascular  System 348 

3.  Ligation  of  Arteries  in  Continuity 35^ 

XIX.  Diseases  and  Injuries  of  Bones  and  Joints 389 

1.  Diseases  of  the  Bones •    •  389 

2.  Fractures 404 

3.  Diseases  of  the  Joints 5^° 

4.  Luxations  or  Dislocations 547 

5.  Operations  upon  Bones 5^5 

XX.  Diseases  and  Injuries  of  Muscles,  Tendons,  and  Burs^  .    .  614 

Operations  upon  Muscles  and  Tendons 628 

XXI.  Orthopedic  Surgery °32 

XXII.  Diseases  and  Injuries  of  Nerves 641 

1.  Diseases  of  Nerves "4^ 

2.  Wounds  and  Injuries  of  Nerves 642 

3.  Operations  upon  Nerves "45 

13 


14  CONTENTS. 

PAGE 

XXIII.  Diseases  and  Injuries  of  the  Head 649 

1.  Diseases  of  the  Head 649 

2.  Injuries  of  the  Head 658 

XXIV.  Surgery  of  the  Spink 693 

XXV.  Surgery  of  the  Respiratory  Organs 713 

1.  Diseases  and  Injuries  of  the  Nose  and  Antrum  .    .    .    .  713 

2.  Diseases  and  Injuries  of  the  Larynx  and  Trachea  .    .    .  7 '5 

3.  Operations  on  the  Larynx  and  Trachea 719 

4.  Diseases  and  Injuries  of  the  Chest,  Pleura,  and  Lungs  .  723 

5.  Operations  on  Pleura  and  Lung 735 

XXVI.  Diseases  and  Injuries  of  the  Upper  Digestive  Tract  741 

XXVII.  Diseases  and  Injuries  of  the  Abdomen 760 

1.  Stomach  and  Intestines 7^8 

2.  The  Peritoneum 795 

3.  The  Liver  and  Gall-bladder 802 

4.  The  Pancreas 810 

5.  The  Spleen •-....  812 

6.  Operations  upon  the  Abdomen 813 

XXVIII.  Diseases  and  Injuries  of  the  Rectum  and  Anus    .    .  875 

XXIX.  Anesthesia  and  Anesthetics 893 

XXX.  Burns  and  Scalds 91 ' 

XXXI.  Diseases  of  the  Skin  and  Nails 915 

XXXII.  Diseases  and  Injuries  of  the  Thyroid  Gland  ....  919 

XXXIII.  Diseases  and  Injuries  of  the  Lymphatics 923 

XXXIV.  Bandages 927 

XXXV.  Plastic  Surgery 93^ 

XXXVI.  Diseases  and  Injuries  of  the  Genitourinary  Organs  942 

1.  Diseases  and  Injuries  of  the  Kidney  and  Ureter     .    .    .  948 

2.  Diseases  and  Injuries  of  the  Bladder 965 

3.  Diseases  and  Injuries  of  the  Urethra,  Penis,  Testicles, 
Prostate,  Seminal  Vesicles,  Prostatic  Cord,  and  Tunica 
Vaginalis 994 

XXXVII.  Amputations io35 

Special  Amputations 1040 

XXXVIH.  Diseases  of  the  Breast 1055 

XXXIX.  Skiagraphy,  or  the  Employment  of  the  Rontgen  Rays  1068 
XL.  Injuries  by  Electricity 1078 


INDEX 


1083 


MODERN    SURGERY 


Modern  Surgery. 


I.  BACTERIOLOGY. 


Bacteriology  is  the  science  of  micro-organisms.  Though 
a  science  in  the  youth  of  its  years,  bacteriology  has  not  only 
profoundly  altered,  but  it  has  also  revolutionized,  pathology, 
and  our  views  of  surgery  would  be  incomplete,  misleading, 
and  erroneous  w^ithout  its  aid. 

Micro-organisms,  microbes,  or  bacteria,  are  minute 
non-nucleated  vegetable  cells  of  the  class  fungi,  many  of 
them  being  visible  only  by  means  of  a  highly  powerful 
microscope  and  after  they  have  been  brightly  stained.  The 
contents  of  these  cells  are  protoplasm  and  nuclear  chromatin 
enclosed  by  a  structure  containing  cellulose.  The  proto- 
plasm can  be  stained  with  anilin  colors,  and  the  cell-wall  is 
more  readily  detected  after  treating  it  with  water,  w^hich 
causes  it  to  swell.  Many  microbes  are  colored,  others  are 
colorless.  Some  move  (motile  bacteria),  others  do  not  move 
(amotile  bacteria) ;  among  the  motionless  ones  may  be  men- 
tioned the  bacilli  of  anthrax  and  tubercle,  and  all  cocci. 
Most  bacteria  can  change  from  motile  to  amotile  or  from 
amotile  to  motile  w^hen  subjected  to  changed  conditions  of 
life.  The  oscillations  of  cocci  are  physical  and  not  vital  in 
nature ;  they  are  Brunonian  or  Brownian  movements,  move- 
ments due  to  alterations  in  equilibrium  because  of  currents 
or  changes  of  level  in  the  fluid  in  which  the  organisms  are 
held.  Bacteria  possess  the  power  of  attracting  elements 
necessar}^  for  their  nutrition  (positive  chemiotaxis  or  chemo- 
taxis),  and  of  repelling  elements  antagonistic  to  them  (nega- 
tive chemiotaxis  or  chemotaxis). 

Definite  knowledge  of  these  minute  bodies  and  of  their 
actions  dates  from  the  study  of  fermentation  by  the  cele- 
brated Frenchman  Pasteur,  who  in  1858  asserted  that  every 
fermentation  has  invariably  its  specific  ferment ;  that  this 
ferment  consists  of  living  cells  ;  that  these  cells  produce  fer- 
mentation by  absorbing  the  oxygen  of  the  substance  acted 
2  17 


1 8  BACTERIOLOGY. 

upon ;  that  putrefaction  is  caused  by  an  organized  ferment ; 
that  all  organized  ferments  are  carried  about  in  the  air ;  and 
that  entirely  to  exclude  air  prevents  putrefaction  or  fermenta- 
tion. These  statements,  which  were  radical  departures  from 
accepted  belief,  inaugurated  a  bitter  controversy,  and  in  that 
controversy  were  born  the  microbic  theory  of  disease,  the 
doctrine  of  preventive  inoculation,  antiseptic  surgery,  and 
serum-therapy. 

The  word  viicrobe,  which  signifies  a  small  living  being,  was 
introduced  in  1878  by  the  late  Professor  Sedillot,  of  Paris.  At 
that  time  the  nature  of  these  bodies  was  in  doubt ;  some 
thought  them  animal,  and  called  them  microzoaria ;  others 
thought  them  vegetable,  and  called  them  Diicropliyta ;  the 
designation  "  microbe  "  does  not  commit  us  to  either  view. 
We  now  know  them  to  be  vegetable,  but  the  term  "  mi- 
crobe "  has  remained  in  use. 

The  micro-organisms  connected  with  disease  in  man  are 
divided  into  three  classes  : 

1.  Yeasts,  Saccharomyces,  or  Blastomycetes  ; 

2.  Moulds,  or  Hyphomycetes  ; 

3.  Bacteria,  or  Schizomycetes. 

Yeasts  include  most  of  those  fungi  which  can  cause  alco- 
holic fermentation  in  saccharine  matter.  They  consist  of 
small  cells  which  can  live  without  free  oxygen,  and  which 
multiply  by  gemmation  or  budding.  When  a  cell  multi- 
plies a  small  bud  of  protoplasm  projects  from  or  near  the 
end  of  the  cell.  This  bud  increases  progressively  in  size  and 
a  constriction  appears  between  the  bud  and  the  parent-cell. 
The  constriction  deepens  as  the  projection  enlarges,  until 
the  bud  attains  the  size  of  the  parent.  Thus  a  chain  or 
series  of  rounded  yeast-cells  is  formed.  These  cells  contain 
spores  when  nourishment  is  insufficient.  The  yeasts  resem- 
ble algae  in  many  respects,  but  contain  chlorophyll,  and  are 
to  be  regarded  as  fungi.  The  chief  importance  of  yeasts  is 
that  they  cause  fermentation ;  they  never  invade  human 
tissues,  though  they  can  dwell  on  mucous  membranes,  and 
even  in  the  stomach.  O'idium  albicans  is  a  yeast-fungus 
whose  growth  upon  the  mucous  membrane  of  the  mouth, 
pharynx,  and  esophagus  causes  the  disease  known  as 
"thrush."  Pekelharing  says  that  pityriasis  is  due  to  the 
saccharomyces  capillitii. 

Moulds  consist  of  filaments,  each  filament  being  composed 
of  a  single  row  of  cells  arranged  end  to  end,  and  all  filaments 
springing  from  a  germinal  tube  which  grows  from  a  germi- 
nating spore.     Moulds  are  largely  connected  with  processes 


BACTERIA. 


19 


of  decay.  Some  of  them  grow  upon  inflamed  mucous  mem- 
brane, and  some  invade  the  epidermis,  producing  certain  skin 
diseases  (favus,  tinea  tonsurans,  tinea  versicolor,  etc.). 

Actinomycosis  (Fig.  i)  and  Madura-foot  arise  from  the 
lodgement  and  growth  of  moulds.  Actinomycosis  is  a  disease 
seen  in  cattle,  and  occasionally  in  men,  especially  in  drovers. 
Cattle  become  infected  usually  through  their  food,  the  fun- 
gus entering  by  a  hollow  tooth  or  by  a  breach  of  continuity 
in  mucous  membrane.  The  lower  jaw  is  usually  the  seat  of 
involvement  in  cattle  (lumpy  jaw).  A  tumor  forms,  which  con- 
tains sero-pus,  and  after  a  time  ruptures  and  discharges  mat- 
ter containing  nodules  composed  of  fungi.  The  bone  may 
undergo  extensive  destruction. 
Other  bones  and  various  organs 
may  be  infected. 

Madiira-foot,  or  mycetoma,  is 
an  endemic  disease  of  India,  which 
is  probably  due  to  infection  with 
the  chionypha  Carteri.    The  foot 

swells  and  becomes  covered  with         p,^  x.-Actinomyces  (ZiegUr)-. 
pustules ;  the  pustules  rupture  and 

expose  sinuses  ;  each  sinus  is  lined  with  a  firm  membrane  and 
is  filled  with  material  which  looks  like  the  roe  of  a  fish.  The 
bones  are  often  extensively  destroyed,  and  gangrene  not  un- 
commonly arises. 

Bacteria  chiefly  claim  our  attention.  It  is  important  to 
remember  that  the  term  "  bacteria,"  though  applied  to  the 
class  schizoinycetes,  has  also  a  more  restricted  application — 
that  is,  to  a  division  of  the  class ;  it  may  mean  either  scliizo- 
inycetes  in  general,  or  rod-shaped  scJiizouiycetes,  whose  length 
is  not  more  than  twice  their  breadth. 

Some  of  the  scliizomycctcs  induce  certain  fermentations ; 
others  grow  upon  dead  organic  matter,  but  are  not  able  to 
invade  living  tissues,  and  are  called  saprophytes  or  non- 
pathogenic bacteria ;  still  others,  known  as  the  pathogenic, 
invade  living  tissue  and  cause  various  diseases.  Parasitic 
bacteria  can  grow  on  or  in  the  tissues  of  the  body.  Obligate 
parasites  are  those  which  have  not  been  cultivated  outside 
of  the  body  (as  the  bacilli  of  leprosy).  Facziltative  parasites 
usually  live  outside  the  body,  but  may  enter  into  the  body 
and  produce  disease.  The  schizomycetes  vary  much  in 
shape,  size,  color,  arrangement,  mode  of  growth,  and  action 
upon  the  body.  One  form  cannot  be  transformed  into 
another,  but  each  maintains  its  specific  identity.  Every 
organism  comes  from  a  pre-existing  organism,  this  being  true 


20 


BACTERIOLOGY. 


of  all  forms.     Pasteur  proved  that  spontaneous  generation  is 
impossible. 

Forms  of  Bacteria. — The  three  chief  forms  of  bacteria 
are — 

1.  The     Coccus    or   Micrococais — berry-shaped,    oval,    or 
round  bacterium  (Fig.  2) ; 

2.  The  Bacillus — rod-shaped  bacterium  (Fig.  3) ; 

3.  The  SpirilluJii — corkscrew-shaped  or  spiral  bacterium 
(Fig.  4).    A  short  spiral  organism  is  called  a  comma  bacillus. 


Fig.  2. — Micrococcus. 


/--• 


Fig.  3. — Bacillus. 


Fig.  4. — Spirillum. 


De  Bary  compares  these  forms,  respectively,  to  the  bil- 
liard-ball, the  lead-pencil,  and  the  corkscrew. 

Cocci  and  Bacilli. — We  have  to  do  only  with  cocci  and 
bacilli.  Cocci  may  be  designated  according  to  their  arrange- 
ment with  one  another ;  namely,  when  existing  singly  they 


^^ 


/ 


Fig.  5. — Forms  of  cocci. 


Fig.  6.— Zooglea  (Ball). 


are  called  monococci ;  in  pairs  they  are  called  diplococci  (Fig. 
5,  a)  ;  in  a  chain  they  are  called  streptococci  (Fig.  5,  c) ;  in  a 
cluster  like  a  bunch  of  grapes  they  are  called  staphylococci 
(Fig.  5,  b)  ;  in  groups  of  four  they  are  called  tetracocci;  in 
groups  of  eight  they  are  called  sarcina  or  wool-sack  cocci. 
Irregular  masses,  resembling  frog-spawn,  constitute  zooglea 
masses  (Fig.  6).     The  gelatinous  matter  in  such  a  mass  is 


MULTIPLICATION  OF  BACTERIA. 


21 


formed  by  a  transformation  in  the  walls  of  the  bacteria.  The 
term  ascococci  is  applied  to  a  group  of  cocci  enclosed  in  a 
capsule  (G.  S.  Woodhead). 

The  cocci  are  often  named  according  to  their  function,  as, 
for  example,  "pyogenic,"  or  pus-forming.  Cocci  may  be 
named  according  to  the  color  of  the  culture.  The  name 
may  embody  the  form,  arrangement,  color,  and  function  ;  for 
instance,  Staphylococais  pyogenes  aureus  signifies  a  round, 
crolden-yellow  micro-organism,  which  arranges  itself  with  its 
fellows  'in  the  form  of  a  bunch  of  grapes,  and  which  pro- 
duces pus. 

The  baeilli  d.re  long,  staff-shaped  organisms.  Long,  deli- 
cate, jointed  bacilli  having  wavy  outlines  are  known  as  lepto- 
thrix  forms.  Chain-like  bacilli  are  called  strcpto-bacilli. 
Bacilli  give  origin  to  many  surgical  diseases. 

Multiplication  of  Bacteria.— Bacteria  multiply  with 
great  rapidity  when  placed  under  suitable  conditions.  They 
can  multiply  by  fission  or  by  spore-formation.  Some  bacteria 
multiply  by  both  methods.  In  fission,  or  segmentation,  the 
cell  elongates  and  about  its  middle  a  constriction  begins, 
which  deepens  until  the  cell  has  divided  into  two  parts, 
each  of  which  soon  grows  as  large  as  its  parent  (Figs.  7,  8). 


Fig.  7.— Divisions  of  a  micrococcus  (after  Mace) 


Fig.  8. — Divisions  of  a  bacillus  (after  Mace). 

All  cocci  and  some  bacilli  multiply  by  this  method.  If 
segmentation  of  a  single  cell  and  the  growth  to  maturity 
of  its  products  require  one  hour  (it  really  takes  place  in  less 
time  the  cholera  bacillus  requiring  but  twenty  minutes  to 
divide),  a  single  cell  in  a  single  day,  if  the  conditions  for  in- 
crease are  ideally  favorable,  will  have  sixteen  mi  lion  de- 
scendants, and  in  three  days  the  mass  of  new  cells  would 
weigh  7500  tons  (Cohn).     In  order,  however,  for  such  enor- 


22 


BACTERIOLOGY. 


mous  multiplication  to  occur  conditions  would  have  to  be 
absolutely  favorable  to  the  cells,  and  conditions  are  never 
absolutely  favorable.  Were  it  otherwise  all  other  forms  of 
life  would  be  destroyed. 

Spores. — A  spore  is  a  germ,  and  corresponds  with  the 
seed  of  a  plant.  Most  of  the  bacilli  multiply  by  spore- 
formation.  Cocci  do  not  undergo  spore-formation  after  the 
manner  of  bacilli,  though  some  observers  maintain  that 
cocci  occasionally  undergo  an  alteration  that  makes  them 
very  resistant  to  any  destructive  influences  (arthrospores). 
When  spore-formation  is  about  to  occur  in  a  bacillus  points 
of  cloudiness  appear  in  the  protoplasm,  the  cell  generally 
elongates,  and  in  twenty-four  hours  the  cell  is  found  to  consist 
of  a  series  of  segments  like  a  necklace  of  beads,  each  segment 
containing  a  full-grown  spore  (Fig.  9).     The  wall  of  the  cell 

now  liquefies,  the  segm.ents 
separate,  the  spores  are  set 
free,  and  each  spore  under 
favorable  conditions  be- 
comes a  bacillus.  When 
the  initial  cloudiness  ap- 
pears in  the  middle  of  the 
cell  and  but  one  spore 
forms,  it  is  called  an  "  endo- 
spore;"  when  it  appears  at 
one  or  both  extremities  it 
is  christened  an  "  end- 
spore "  or  "endspores." 
When  multiplication  is  by 
a  single  endospore  the  ba- 
cillus does  not  elongate.  When  multiplication  takes  place 
by  a  process  of  combined  spore-formation  and  fission  the 
mother-cell  divides  into  a  number  of  daughter-cells,  which 
are  called  arthrospores.  Organisms  which  when  active 
multiply  by  fission  take  on  spore-formation  when  subjected 
to  certain  conditions. 

Spore-formation  tends  to  occur  when  bacilli  are  about  to 
die  for  want  of  nourishment  or  when  there  is  an  excess  of 
oxygen  present.  Each  cell,  as  a  rule,  contains  but  one  spore, 
but  may  contain  several.  The  spore  has  a  dense  envelope 
or  covering  which  is  veiy  resistant  to  destructive  agents.  So 
resistant  is  the  covering  that  twice  the  amount  of  heat  is 
necessary  to  kill  a  spore  as  to  kill  an  active  adult  cell. 
Spores  when  placed  under  conditions  unfavorable  for  devel- 
opment may  remain  inactive  for  an  indefinite  period,  just  as 


Fig.  9. — Sporulation  (after  De  Bary). 


LIFE-CONDITIONS   OF  BACTERIA.  23 

seeds  remain  inactive  when  unplanted.  When  spores  en- 
counter favorable  conditions  they  at  once  develop  into  adult 
cells,  just  as  seeds  develop  when  planted.  It  seems  prob- 
able that  spores  occasionally  remain  dormant  in  the  human 
body  for  long  periods,  and  finally  awaken  into  activity  be- 
cause of  injury  or  disease  of  the  tissue  in  which  they  lie. 

lyife- conditions  of  Bacteria. — In  order  to  grow  and 
to  multiply,  bacteria  require  a  suitable  soil  and  the  favoring 
influences  of  heat  and  moisture.  The  soil  demanded  con- 
sists of  highly  organized  compounds  rather  than  crude  sub- 
stances, and  slight  modifications  in  it  may  prove  fatal  to 
some  forms  of  bacterial  life,  but  highly  advantageous  to 
others.  Some  organisms  require  albuminous  matter,  others 
need  carbohydrates  ;  they  all  require  water,  carbon,  nitrogen, 
oxygen,  hydrogen,  and  certain  inorganic  materials,  especially 
hme  and  potassium  (Woodhead).  All  organisms  require 
water.  If  dried,  no  micro-organisms  will  multiply,  and 
many  forms  will  die.  The  fluid  and  tissues  of  the  individual 
may  or  may  not  afford  a  favorable  soil  for  the  germs  of  a 
disease,  or,  in  the  same  person,  may  afford  it  at  one  time 
and  not  at  another.  Some  individuals  seem  to  possess 
inde'structible  immunity  from,  and  others  are  especially 
prone  to,  certain  contagious  diseases.  Impairment  of  health, 
by  altering  some  subtle  condition  of  the  soil,  may  make  a 
person  liable  who  previously  was  exempt. 

The  presence  of  oxygen  influences  microbic  growth.  Most 
organisms  thrive  best  when  exposed  to  the  oxygen  of  the 
air,  and  they  are  known  as  "  aerobic."  The  term  "  anaero- 
bic" is  employed  to  designate  organisms  that  can  grow  and 
multiply  and  produce  particular  products  only  when  air  is 
absent,  free  oxygen  being  fatal  to  them.  Tetanus  bacilli 
and  the  bacilli  of  malignant  edema  are  anaerobic.  An 
organism  which  can  grow  indifferently  where  oxygen  is  abun- 
dant or  where  free  oxygen  is  absent  is  called  a  "  faculta- 
tive-aerobic "  bacterium.  It  may  need  oxygen  ;  but  if  it  does, 
it  is  able  to  obtain  it  from  the  tissues  when  air  is  excluded. 
A  sensitive  organism  which  dies  when  the  amount  of  oxygen 
is  even  slightly  diminished  is  called  an  "  obligate-aerobic  " 
bacterium.  Most  microbic  diseases  in  man  are  due  to  facul- 
tative-aerobic bacteria. 

Effect  of  Motion,  Sunlight,  Heat,  and  Cold. — The 
majority  oi fungi  grow  best  when  at  rest;  agitation  retards 
the  growth  of  some  and  kills  others.  Sunlight  antagonizes 
the  growth  of  certain  bacteria,  especially  tubercle  bacilli  and 
the  bacilli  of  typhoid  fev^er.     Temperature  influences  bacte- 


24  BACTERIOLOGY. 

rial  growth.  Some  organisms  will  only  grow  within  narrow 
temperature-limits,  while  others  can  sustain  sweeping  altera- 
tions, but  most  grow  best  between  the  limits  of  from  86°  to 
104°  F.  Freezing  renders  bacteria  motionless  and  incapa- 
ble of  multiplication,  but  it  does  not  kill  them  :  they  again 
become  active  when  the  temperature  is  raised.  The  absurd- 
ity of  employing  cold  as  a  germicide  is  evident  when  the  fact 
is  known  that  a  temperature  of  200°  F.  below  zero  is  not 
fatal  to  germ-life,  cell-activities  by  such  a  temperature  only 
being  rendered  dormant.  High  temperatures  are  fatal  to 
bacteria ;  moist  heat  is  more  destructive  than  dry  heat,  and 
adult  cells  are  more  easily  killed  than  spores.  A  temperature 
less  than  212°  F.  will  kill  many  organisms,  and  boiling  will 
kill  every  pathogenic  organism  that  does  not  form  spores. 
Some  spores  are  not  destroyed  after  prolonged  boiling,  and 
some  will  withstand  a  temperature  of  1 20°  C.  As  a  practical 
fact,  however,  boiling  water  kills  in  a  few  minutes  all  cocci, 
most  bacilli,  and  all  pathogenic  spores ;  though  the  spores 
of  anthrax,  tetanus,  and  malignant  edema  are  harder  to  kill 
than  are  the  spores  of  other  bacteria. 

Chemical  Antiseptics  and  Germicides. — It  is  neces- 
sary to  make  a  distinction  between  deodorizers,  antiseptics, 
and  germicides. 

A  deodorizer  is  an  agent  which  destroys  an  offensive  odor. 
It  is  true  that  an  offensive  odor  may  be  due  to  microbic 
growth.  It  is  also  true  that  nasty  odors  may  prove  injurious 
to  those  who  inhale  them.  But,  nevertheless,  the  odor  is 
the  result  of  microbic  action,  and  destroying  an  odor  does 
not  render  harmless  the  bacteria  which  caused  it.  Charcoal 
is  a  well-known  deodorizer. 

An  antiseptic  is  an  agent  which  retards  or  prevents  putre- 
faction. It  acts  by  weakening  or  killing  saprophytic  organ- 
isms. 

A  germicide  or  disinfectant  is  an  agent  which  is  fatal  to 
bacteria.  The  destruction  of  the  germs  of  disease  in  cloth- 
ing, in  excreta,  in  a  wound,  etc.,  is  known  as  disinfection. 
Disinfection  of  a  wound,  dressings,  or  instruments  is  called 
also  sterilization. 

Many  chemical  agents  will  kill  bacteria,  the  most  certain 
of  them  all  being  corrosive  sublimate.  Koch  showed  that 
corrosive  sublimate  is  an  efficient  test-tube  germicide  when 
present  in  the  proportion  of  only  i  part  to  50,000.  It  is  used 
in  surgery  in  strengths  of  i  part  of  the  salt  to  1000,  2000, 
3000,  or  more  parts  of  water.  Badly  infected  wounds  are 
occasionally  irrigated  with  solutions  of  a  strength  of  i   to 


CHEMICAL    ANTISEPTICS  AND    GERMICIDES.  25 

500.  Contact  with  albumin  precipitates  from  a  solution  of 
corrosive  sublimate  an  insoluble  albuminate  of  mercury 
which  forms  upon  the  surface  of  the  wound,  is  not  a  germi- 
cide, and  prevents  deep  diffusion  of  the  mercurial  fluid.  In 
surgical  operations  b\'  the  antiseptic  method  the  mercurial 
salt  should  be  combined  with  tartaric  acid  in  the  proportion 
of  I  to  5,  which  combination  prevents  the  formation  of  the 
insoluble  albuminate  of  mercury. 

But  though  corrosive  sublimate  under  certain  conditions 
is  very  powerful,  it  is  not  always  absolutely  reliable.  Man}- 
spores  are  ver}'  resistant  to  its  action.  Even  a  i  per  cent, 
solution  of  bichlorid  of  mercury  is  not  certainl}'  destructive 
of  the  spores  of  anthrax.  Geppert  tells  us  that  anthrax-spores 
maybe  active  after  a  25-hour  immersion  in  a  i  :  100  solution 
of  sublimate  (Schimmelbusch).  In  the  presence  of  hydrogen 
sulphid  corrosive  sublimate  is  useless,  inert  and  insoluble 
sulphid  of  mercury  being  precipitated  ;  hence  corrosive  sub- 
limate is  without  value  as  a  rectal  antiseptic ;  in  fact,  Gerl- 
oczy  has  proved  that  a  concentrated  aqueous  solution  of 
sublimate  will  not  disinfect  an  equal  quantit}'  of  feces.  Cor- 
rosive sublimate  contained  in  dressings  after  a  time  undergoes 
decomposition  and  ceases  to  be  a  germicide.  It  is  not  ger- 
micidal in  fatty  tissues  because  it  is  unable  to  attack  bacteria 
which  are  coated  with  oil.  Corrosive  sublimate  is  very  irri- 
tating to  the  tissues  and  causes  copious  exudation.  Hence, 
after  tissues  have  been  irrigated  with  this  agent  drainage 
must  be  employed.  In  some  cases  the  irritated  tissues  lose 
to  a  great  extent  their  power  of  resistance,  and  infection  may 
be  actually  facilitated  b}'  irrigation  with  sublimate.  In  rare 
instances  corrosive  sublimate  is  absorbed  and. produces  poi- 
soning. In  spite  of  these  shortcomings  and  drawbacks  it  is 
a  valuable  aid  to  the  surgeon  and  must  be  frequently  used, 
especially  upon  the  skin  of  the  patient  and  the  hands  of  the 
operator  and  his  assistants.  It  should  be  dissoh'ed  in  dis- 
tilled water,  because  ordinar}'  water  causes  a  precipitate  to 
form  (common  salt  prevents  the  formation  of  this  precipi- 
tatel 

Because  of  the  fact  that  corrosive  sublimate  is  poison- 
ous and  very  irritant,  it  should  not  be  used  upon  serous 
membranes.  It  is  absorbed  quickh-  from  serous  membranes 
and  destroys  the  endothelial  cells,  and  should  not  be  intro- 
duced into  the  pleural  sac,  into  joints,  or  into  the  peritoneal 
cavit)-.  It  should  never  be  put  within  the  dura,  and  should 
not  be  applied,  in  strong  solution  at  least,  to  mucous  mem- 
branes.  It  is  better  to  make  the  solution  when  it  is  needed,  so 


26  BAC  TERIOL  OGY. 

as  to  have  it  fresh,  for  in  old  solutions  much  of  the  soluble 
corrosive  sublimate  has  been  converted  into  insoluble  oxy- 
chlorid,  and  the  fluid  has  ceased  to  be  germicidal.  In  order 
to  make  up  fresh  solutions  use  tablets,  each  of  which  con- 
tains about  ']\  grains  of  the  drug — one  of  these  tablets  added 
to  a  pint  of  water  makes  a  solution  of  a  strength  of  i  to 
looo.  Tablets  which  also  contain  ammonium  chlorid  are 
more  soluble  than  those  which  contain  corrosive  sublimate 
only.  Hot  solutions  of  the  drug  are  more  powerfully  germi- 
cidal than  cold  solutions.  As  corrosive  sublimate  is  irritant, 
leads  to  profuse  exudation,  and  may  produce  tissue-necrosis, 
it  should  never  be  introduced  into  an  aseptic  wound.  In 
such  a  wound  it  can  do  no  good  and  may  do  much  harm. 

Griffin,  in  Foster's  Practical  Therapeutics,  sets  forth  the 
strengths  of  solutions  applicable  to  different  regions  : 

For  disinfection  of  the  surgeon's  hands  and  the  patient's 
skin,  I  :  lOOO;  forirrigating  trivial  wounds,  i  :  2000  ;  for  irri- 
gating larger  wounds  and  cavities,  i  :  10,000  to  i  :  5000  ;  for 
irrigating  vagina,  i  :  10,000  to  i  :  5000;  for  irrigating  urethra, 
I  :  40,000  to  I  :  20,000;  forirrigating  conjunctiva,  i  :  5000; 
for  gargling,  i  :  10,000  to  i  :  5000. 

Instruments  cannot  be  placed  in  corrosive  sublimate  with- 
out being  dulled,  stained,  and  corroded. 

Corrosive  sublimate  may  be  absorbed  from  a  wound,  a 
serous  surface,  or  a  mucous  membrane,  ptyalism  and  diar- 
rhea resulting.  The  absorption  of  bichlorid  of  mercury  may 
be  followed  by  cramp  in  the  limbs  and  belly,  feeble  pulse, 
cold  skin,  extreme  restlessness,  and  even  collapse  and  death. 
At  the  first  sign  of  trouble  withdraw  the  drug  and  treat  the 
ptyalism  (page  257). 

Carbolic  acid  is  a  valuable  germicide  in  the  strength  of 
from  I  :  40  to  I  :  20.  It  is  certainly  fatal  to  pus-organisms, 
but  weak  solutions  do  not  destroy  spores.  Unfortunately, 
this  acid  attacks  the  hands  of  the  surgeon  ;  consequently  in 
the  United  States  it  is  chiefly  employed  as  an  antiseptic  me- 
dium in  which  to  place  the  sterilized  operating-instruments, 
or  as  a  germicide  to  prepare  the  skin  of  the  patient  before 
the  operation  is  performed. 

Carbolic  acid  is  very  irritant  to  tissues,  and  carbolized 
dressings  may  be  responsible  for  sloughing  of  the  wound  or 
dry  gangrene.  Because  of  its  irritant  properties  wounds 
which  have  been  irrigated  with  it  should  be  well  drained. 
CarboHc  acid,  like  corrosive  subhmate,  is  inert  in  fatty  ti.s- 
sues.  Carbolic  acid  is  readily  absorbed,  and  may  thus  pro- 
duce toxic  symptoms.     Absorption  is   not  uncommon  when 


CARBOLIC  ACID.  2/ 

the  weaker  solutions  are  used,  but  rarely  occurs  when  a 
wound  has  been  brushed  over  with  pure  acid,  because  the 
pure  acid  at  once  forms  an  extensive  zone  of  coagulation, 
which  acts  as  a  barrier  to  absorption.  One  of  the  early  indi- 
cations of  the  absorption  of  carbolic  acid  is  the  assumption 
by  the  urine  of  a  smoky,  greenish,  or  blackish  hue.  This 
hue  appears  a  little  time  after  the  urine  has  been  voided, 
whereas  the  smoky  hue  of  hematuria  is  noted  in  urine  at  once 
after  it  has  been  passed.  The  condition  produced  by  carbolic 
acid  is  known  as  carboluria,  and  examination  of  such  urine 
shows  a  great  diminution  or  entire  absence  of  sulphates  when 
the  acidulated  urine  is  heated  with  chlorid  of  barium.  The 
diminution  of  precipitable  sulphates  is  explained  by  the  fact 
that  these  salts  are  combined  w^ith  carbolic  acid,  forming  sol- 
uble sulphocarbolates  (Griffin).  Such  urine  is  apt  to  contain 
albumin.  If  during  the  use  of  carbolized  dressing  or  the 
employment  of  carbolic  solutions  the  urine  becomes  smoky, 
the  use  of  the  drug  in  any  form  must  be  at  once  discon- 
tinued, otherwise  dangerous  symptoms  will  soon  appear. 
These  symptoms  are  subnormal  temperature,  feeble  pulse 
and  respiration,  muscular  weakness,  and  vertigo.  If  death 
occurs,  it  is  due,  as  a  rule,  to  respiratory  failure.  The  treat- 
ment of  slow  poisoning  by  carbolic  acid  consists  in  at  once 
withdrawing  the  drug,  giving  stimulants  and  nourishing  food, 
administering  sulphate  of  sodium  several  times  a  day  and 
atropin  in  the  morning  and  evening. 

Pure  carbolic  acid  is  a  reliable  disinfectant  for  certain  con- 
ditions. It  is  used  to  destroy  chancroids,  to  purify  infected 
areas,  to  disinfect  the  medullary  cavity  in  osteomj-elitis,  to 
stimulate  granulation  after  the  open  operation  for  hydrocele 
or  to  purify  sloughing  burns.  The  pure  acid  rarely  pro- 
duces constitutional  symptoms,  but  it  occasionally  causes 
sloughing.  Its  application  causes  pain  for  a  moment  only, 
and  then  analgesia  ensues.  Even  dilute  solutions  of  carbolic 
acid  greatly  relieve  pain  when  applied  to  raw  surfaces. 

Carbolic  acid  is  certainly  fatal  to  but  few  bacteria  and  it 
fails  to  kill  most  spores.  It  acts  more  slowly  and  less  cer- 
tainly than  corrosive  sublimate.  It  requires  twenty-four 
hours  for  a  5  per  cent,  solution  to  kill  anthrax-spores.  _  Pus 
or  blood  (albuminous  matter)  greatly  weakens  the  germicidal 
power  of  carbolic  acid,  and  fatty  tissue  cannot  be  disinfected 
by  it.  It  is  not  even  the  best  of  agents  in  which  to  place  in- 
struments, as  it  dulls  them.  After  operation  upon  the  mouth 
it  is  used  as  a  wash  or  gargle,  i  to  2  per  cent,  being  a  suitable 
streno-th.     It  is  used  sometimes  to  irrigate  the  bladder  and 


2  8  BACTERIOL  OGY. 

often  to  cleanse  sinuses,  but  is  not  employed  in  the  perito- 
neal cavity,  the  pleural  sac,  or  the  brain.  It  is  occasionally 
injected  into  tubercular  joints. 

Creolin,  which  is  a  preparation  made  from  coal-tar,  is  a 
germicide  without  irritant  or  toxic  effects.  It  is  less  power- 
ful than  carbolic  acid,  but  acts  similarly,  and  is  used  in  emul- 
sion of  a  -Strength  of  from  i  to  5  per  cent.,  and  does  not  irri- 
tate the  skin  like  carbolic  acid. 

Peroxid  of  hydrogen  is  an  excellent  agent  for  cleansing 
a  purulent  or  putrid  area.  It  comes  in  a  15-volume  solu- 
tion, which  should  be  diluted  one-half  or  two-thirds.  It 
probably  destroys  the  albuminous  element  upon  which  bac- 
teria live,  and  starves  the  fungi.  When  peroxid  of  hydrogen 
is  applied  to  a  purulent  area  ebullition  occurs,  liberated  oxy- 
gen bubbling  up  through  the  fluid  and  the  pus  being  oxi- 
dized. The  peroxid  of  hydrogen  is  not  fatal  to  tetanus 
bacilli ;  in  fact,  tetanus  bacilli  can  be  cultivated  in  a  strong 
solution  of  it.  Some  surgeons  use  it  to  wash  out  appendic- 
ular abscesses.  It  must  not  be  injected  into  a  deep  abscess 
in  any  region  unless  a  large  opening  exists,  as  otherwise  the 
evolved  gas  may  tear  apart  structures  and  dissect  up  the 
cellular  tissue.  In  a  deep  abscess  of  the  neck  the  author 
saw  this  agent  almost  produce  suffocation,  the  gas  passing 
under  the  mucous  membranes  and  nearly  blocking  the  air-' 
passages.  Peroxid  of  hydrogen  should  not  be  applied  to 
an  aseptic  wound.  The  use  of  peroxid  should  not  be  too 
long  continued,  for  if  used  for  a  considerable  period  it  makes 
the  granulations  edematous  and  retards  healing.  In  fact, 
its  continued  use  may  actually  prevent  a  sinus  closing. 

Iodoform  is  largely  used  ;  it  is  not  truly  a  germicide,  as 
bacteria  will  grow  upon  it,  but  it  hinders  the  development 
of  bacteria  and  directly  antagonizes  the  action  of  the  toxic 
products  of  germ-life.  It  can  be  rendered  sterile  by  washing 
with  a  solution  of  corrosive  sublimate.  It  is  of  the  greatest 
value  when  applied  to  infected  areas  and  tubercular  proc- 
esses. Clinically,  no  real  substitute  for  it  has  yet  been 
found.  It  need  not  be  applied  to  clean  wounds,  but  the 
powder  is  very  useful  when  dusted  into  infected  wounds.  It 
prevents  wound-discharges  from  decomposing  and  distinctly 
allays  pain.  Gauze  impregnated  with  iodoform  is  used  to 
keep  abscesses  open  after  evacuation,  to  drain  the  belly 
after  certain  operations,  to  pack  aside  the  intestines  and 
prevent  their  infection  during  some  abdominal  operations, 
and  as  packing  to  arrest  intracranial  hemorrhage.  Iodo- 
form gauze  will   drain  serum  well,  but  will  not  drain  pus. 


IODOFORM.  29 

In  fact,  it  blocks  up  a  pus-cavity,  and  if  retained  long  leads 
to  the  collection  of  purulent  matter  behind  and  about  the 
supposed  drain.  If  used  in  an  abscess,  it  must  be  removed 
in  twenty-four  or  thirty-six  hours.  Tubercular  joints  and 
cold  abscesses  are  injected  with  iodoform  emulsion,  which  is 
made  by  adding  the  drug  to  sterile  glycerin  or  olive  oil. 
The  emulsion  contains  10  per  cent,  of  iodoform.  A  solution 
in  ether  of  a  strength  of  10  per  cent,  may  be  used  to  inject 
the  cavity  of  a  cold  abscess. 

The  drug  must  be  used  with  some  caution.  Absorption 
from  a  wound  sometimes  happens,  producing  toxic  symptoms. 
These  symptoms  are  frequently  misinterpreted,  being  usually 
attributed  to  infection.  The  symptoms  in  some  cases  are 
acute  and  arise  suddenly,  and  consist  of  a  hallucinatory  de- 
lirium, nausea,  fever,  watery  eyes,  contracted  pupils,  metallic 
taste  in  mouth,  yellowness  of  the  skin  and  eyes,  an  odor  of 
iodoform  upon  the  breath,  the  presence  of  the  drug  in  the 
urine,  the  outbreak  of  a  skin  eruption  resembling  measles, 
and  excessive  loss  of  flesh  and  strength.  Patients  with  such 
acute  symptoms  usually  pass  into  coma  and  die  within  a 
week.  Such  attacks  are  most  apt  to  arise  in  those  beyond 
middle  life  (see  Gerster  and  Lilienthal,  in  Foster's  Practical 
Therapeutics).  lodin  can  be  recognized  in  urine  by  adding 
a  few  drops  of  commercial  nitric  acid  and  a  little  chloroform. 
When  the  mixture  is  shaken-  the  chloroform  will  take  up  the 
free  iodin  and  become  purple,  and  on  standing  the  purple 
layer  will  settle  to  the  bottom  of  the  tube.  In  chronic  cases 
of  iodoform-poisoning  the  first  symptoms  usually  observed  are 
moroseness,  bewilderment,  and  irritability,  followed  by  de- 
pression with  unsystematized  persecutory  delusions,  delirium, 
coma,  and   even  death. 

In  systemic  poisoning  by  iodoform,  discontinue  the  use  of 
the  drug  and  sustain  the  strength  of  the  patient  while  nature 
is  removing  the  poison. 

Iodoform  sometimes  produces  great  local  irritation  of  the 
cutaneous  surface,  shown  by  crops  of  vesicles  filled  with  tur- 
bid yellow  serum  or  even  bloody  serum.  These  vesicles 
rupture  and  expose  a  raw  oozing  surface,  looking  not  unlike 
a  burn.  The  use  of  the  drug  must  be  at  once  abandoned, 
for  to  continue  it  will  not  only  increase  the  dermatitis,  but 
will  produce  constitutional  symptoms.  Wash  the  vesicu- 
lated  area  with  ether  to  remove  iodoform,  open  each  vesicle 
and  dress  the  part  for  several  days  with  gauze  wet  with  nor- 
mal salt  solution.  After  acute  inflammation  ceases  apply 
zinc  ointment  or  cosmolin. 


30  BACTERIOLOGY. 

Europhen  is  a  powder  containing  iodin,  and  the  iodin 
separates  from  it  slowly  when  the  powder  is  applied  to 
wounds  or  ulcers.  It  does  not  produce  toxic  symptoms 
readily,  if  at  all,  and  is  a  valuable  substitute  for  iodoform. 
It  is  used  especially  in  the  treatment  of  ulcers  and  burns. 

Nosophen  is  a  pale  yellow  powder  containing  60  per  cent, 
of  iodin.  Its  bismuth  salt  is  known  as  antinosin.  Nosophen 
is  not  toxic,  is  free  from  odor,  and  is  the  best  of  the  substi- 
stutes  for  iodoform. 

Acetanilid  is  frequently  used  as  a  substitute  for  iodoform. 
It  is  of  value  when  applied  to  suppurating,  ulcerating,  or 
slouehing-  areas,    but  it    does   not    benefit    tubercular  con- 

re 

ditions.  Sometimes  absorption  takes  place  to  a  sufficient 
extent  to  cause  cyanosis,  sweating,  and  weakness  of  the  pulse 
and  respiration.  If  cyanosis  arises,  suspend  the  administra- 
tion of  the  drug  and  administer  stimulants  by  the  stomach. 

Silver  is  a  valuable  antiseptic.  Halsted  and  Bolton  have 
shown  that  metallic  silver  exerts  an  inhibitive  action  upon 
the  growth  of  micro-organisms  and  does  not  irritate  the  tis- 
sues. Cred6  has  demonstrated  the  same  facts.  These  state- 
ments indicate  one  great  reason  why  silver  w'ire  is  so  useful 
as  a  suture-material.  Halsted  is  accustomed  to  place  silver 
foil  over  wounds  after  they  have  been  sutured,  and  Crede 
employs  as  a  dressing  a  fabric  in  which  metallic  silver  is  in- 
timately incorporated. 

Crede  considers  silver  lactate  (actol)  an  admirable  anti- 
septic. It  does  not  form  an  insoluble  albuminate  when 
introduced  into  the  tissues  and  is  not  an  irritant.  Silver 
citrate  (itrol)  is  said  to  be  even  a  better  preparation  than 
silver  lactate,  and  it  is  a  useful  dusting-powder. 

Pormaldehyd,  or  formic  aldehyd,  has  valuable  antiseptic 
properties.  Formalin  is  a  40  per  cent,  solution  of  the  gas  in 
water.  Solutions  of  this  strength  are  very  irritant  to  the 
tissues,  but  2  per  cent,  solutions  can  be  used  to  disinfect 
wounds.  The  stronger  solution  is  valuable  for  asepticizing 
chancroids  and  other  ulcers.  The  milder  solution  is  used 
to  irrigate  sinuses,  tubercular  areas,  abscess-cavities,  and 
suppurating  joints.  The  vapor  of  formalin  is  used  to  disin- 
fect wounds,  and  Wood  suggests  its  employment  in  septic 
peritonitis  as  a  means  of  disinfection  after  the  abdomen  has 
been  opened.  A  2  per  cent,  solution  disinfects  instruments 
satisfactorily. 

Pormalin-g-elatin  has  recently  been  introduced  by  Schleich 
as  an  antiseptic  powder.  When  applied  to  a  clean  wound  it 
gives  off  formalin  and  keeps  the  wound  aseptic.     When  it  is 


DISTRIBUriOX   OF  BACTERIA.  3  I 

applied  to  a  sloughing  surface  it  will  not  give  off  formalin 
unless  it  is  mixed  with  pepsin  and  hydrochloric  acid.  The 
commercial  preparation  is  known  as  g-lutol.  Formalin-gela- 
tin has  been  used  to  replace  bone-defects. 

Nucleins,  especially  protonuclein,  possess  germicidal 
powers.  Protonuclein  is  of  value  in  treating  areas  of  in- 
fection, particularly  when  sloughing  exists. 

Among  other  antiseptics  and  germicides  of  more  or  less 
value  we  may  mention  trichlorid  of  iodin,  iodol,  chlorid  of 
zinc,  chlorid  of  iron,  loretin,  salol,  oxyc}-anid  of  mercury, 
fluorid  of  sodium,  argonin,  sugar,  mustard,  lannaiol,  bichlorid 
of  palladium  (in  ver\^  dilute  solution),  thymol,  potash  soap, 
iodin,  salicylic  acid,  boric  acid,  camphor,  eucalyptol,  cinnamon, 
bromin,  chlorin  (as  gas  or  as  chlorin-water),  cinnamic  acid, 
permanganate  of  potassium  or  of  calcium,  chlorate  of  potas- 
sium, alcohol,  normal  salt  solution,  and  oxalic  acid. 

The  best  germicide  is  heat,  and  the  best  form  in  which  to 
apply  heat  is  b}-  means  of  boiling  water  (e^•en  better  than 
steam).  One  can  use  boihng  w^ater  upon  instruments  and 
dressings,  but  rareh-  upon  a  patient.  Jeannel,  of  Toulouse, 
uses  boiling  salt  solution  in  abscess-cavities,  and  some  other 
surgeons  employ  steam  or  boiling  water  to  disinfect  the 
medullary  canal'  in  osteomyelitis.  Nevertheless,  boiling 
water  is  rarely  applied  to  the  patient,  and  in  man}-  cases  a 
chemical  germicide  must  be  used.  The  surgeon  should 
always  scrub  his  hands  in  a  germicidal  solution,  and  corro- 
sive sublimate  is  one  of  the  best  we  possess. 

Distribution  of  Bacteria. — IMicrobes  are  ver}-  widely 
distributed  in  nature.  They  are  found  in  all  water  except 
that  which  comes  from  very  deep  springs ;  in  all  soil  to  the 
depth  of  three  feet ;  and  in  air,  except  that  of  the  desert,  that 
over  the  open  sea,  and  that  of  lofty  mountains. 

jMicrobes  may  be  useful.  Some  of  them  are  scavengers, 
and  clean  the  surface  of  the  earth  of  its  dead  by  the  process 
known  as  "putrefaction,"  in  which  complex  organic  matter 
is  reduced  to  harmless  gases  and  to  a  mineral  condition. 
The  gases  are  taken  up  from  the  air  by  vegetables,  and  the 
mineral  matter  is  dissolved  in  rain-water  and  passes  into  the 
soil  from  which  it  came,  there  again  to  be  food  for  plants, 
which  plants  will  become  food  for  animals.  Other  organ- 
isms purify  rivers  ;  others  cause  bread  to  rise ;  still  others 
give  rise  to  fermentation  in  liquors.  Microbes  may  be  harm- 
ful. The\-  ma}-  poison  rivers  and  soils ;  they  may  be  para- 
sites on  vegetable  life ;  they  cause  diseases  of  the  growing 
vine,  and  also  of  wine ;  they  produce  the  mould  on  stale, 


32  BACTERIOLOGY. 

damp  bread ;  they  occasionally  form  poisonous  matter  in 
sausages,  in  ice-cream,  and  in  canned  goods  ;  and  they  pro- 
duce many  diseases  among  men  and  the  lower  animals. 

With  so  universal  a  distribution  of  these  fuJigi,  man  must 
constantly  take  them  into  his  organism.  They  are  upon 
the  surface  of  his  body,  he  inhales  them  with  every  breath, 
and  he  swallows  them  with  his  food  and  drink.  Most  of 
them,  fortunately,  are  entirely  harmless ;  others  cannot  act 
on  the  living  tissues  ;  but  some  are  virulent,  and  these  are 
generally  but  not  always  destroyed  by  the  cells  of  the  human 
body.  The  alimentary  canal  always  contains  bacteria  of 
putrefaction,  which  act  only  upon  the  dead  food,  and  not 
upon  the  living  body;  but  when  a  man  dies  these  organisms 
at  once  attack  the  tissues,  and  post-mortem  putrefaction 
begins  in  the  abdomen. 

Koch's  Circuit. — To  prove  that  a  microbe  is  the  cause 
of  a  disease  it  must  fulfil  Koch's  circuit.  It  must  always  be 
found  associated  with  the  disease ;  it  must  be  capable  of 
forming  pure  cultures  outside  the  body ;  these  cultures  must 
be  capable  of  reproducing  the  disease ;  and  the  microbe 
must  again  be  found  associated  with  the  artificially  produced 
morbid  process. 

Disease  -  production.  —  Disease-producing  organisms 
which  enter  the  body  are  usually  rapidly  destroyed.  They 
cannot  dwell  there  long  without  inducing  disease,  but  spores 
can  lie  dormant  in  the  system  for  years,  only  waking  into 
activity  when  they  come  in  contact  with  some  damaged, 
weakened,  or  diseased  part  where  the  circulation  is  abnormal 
— a  so-called  point  of  least  resistance  (a  locics  minoris  rcsist- 
enticB) — which  affords  a  nest  for  them  to  develop  and  to  mul- 
tiply, the  cellular  activities  of  the  weakened  part  being  unable 
to  cope  with  the  activities  of  the  germs.  Even  large  num- 
bers of  pathogenic  organisms  may  induce  no  trouble  in  a 
healthy  man  ;  but  let  them  reach  a  damaged  spot,  and  mis- 
chief is  apt  to  arise.  Kocher  established  subcutaneous  bone- 
injuries  in  dogs,  and  these  injuries  pursued  a  healthy  course 
until  the  animal  was  fed  upon  putrid  meat,  whereupon  sup- 
puration took  place.  This  experiment  proves  that  an  organ- 
ism can  reach  a  damaged  area  by  means  of  the  blood,  and 
it  enables  us  to  understand  how  a  knee-joint  can  suppurate 
when  we  merely  break  up  adhesions,  and  how  osteomyelitis 
can  follow  trauma  when  the  skin  is  intact.  A  given  number 
of  organisms  might  produce  no  effect  on  a  healthy  man, 
whereas  the  same  number  might  produce  disease  in  an  indi- 
vidual who  was  weak  or  ill-nourished,  suffering  from  depres- 


PTO  MAINS.  33 

sion  or  fear,  or  debilitated  by  the  habitual  use  of  alcohol. 
The  personal  increment  plays  a  great  part  in  disease-produc- 
tion. Some  individuals  seem  to  be  immune  to  certain  dis- 
eases ;  others  seem  especially  liable  to  develop  certain  dis- 
eases ;  and  these  immunities  and  liabilities  may  be  heredi- 
tary or  acquired,  temporary  or  permanent. 

Toxins. — The  action  of  pathogenic  bacteria  upon  the  tis- 
sues is  of  great  importance.  In  the  first  place,  they  abstract 
from  the  blood,  the  lymph,  and  the  cells  certain  elements 
necessary  to  the  body — as  water,  oxygen,  albumins,  carbo- 
hydrates, etc. — and  thus  cause  body-wasting  and  exhaustion 
from  want  of  food.  In  the  second  place,  bacteria  produce  a 
vast  number  of  compounds,  some  harmless  and  others  highly 
poisonous.  The  symptoms  of  a  microbic  disease  are  largely 
due  to  the  absorption  of  poisonous  materials  from  the  area 
of  infection.  These  poisons  may  be  formed  from  the  tissues 
by  the  action  upon  them  of  the  bacteria  (toxins  and  pep- 
tones) or  may  be  liberated  from  the  bodies  of  degenerating 
microbes  (bacterial  proteid).  Bacteria  contain  and  secrete 
ferments  like  pepsin  or  trypsin,  and  as  albumoses  are  formed 
in  the  alimentary  canal  by  the  action  of  digestive  ferments 
upon  proteids,  sugars,  and  starches,  so  microbic  albumoses 
are  formed  by  the  action  of  microbic  ferments  upon  tissues. 
Just  as  the  albumoses  formed  in  digestion  are  poisonous 
when  injected,  so  the  albumoses  of  microbic  action  are  poi- 
sonous when  absorbed.  The  albumoses  of  microbic  action 
are  called  "  toxalbumins,"  and  these  albumoses  often  operate 
as  virulent  poisons  to  the  body-cells. 

A  number  of  compounds  formed  by  the  microbic  destruc- 
tion of  tissue  are  alkaloidal  in  nature.  These  poisonous 
alkaloids  are  readily  diffusible  and,  many  of  them,  very  viru- 
lent. It  is  probable  that  every  pathogenic  organism  has  its 
own  special  toxin  which  produces  its  characteristic  effects, 
although  the  effects  are  modified  by  the  nature  of  the  soil — 
that  is  to  say,  by  the  condition  of  the  tissues.  The  absorp- 
tion of  toxins  may  be  very  rapid  ;  for  instance,  the  toxins  of 
cholera  may  kill  a  man  before  the  bacillus  has  migrated  from 
the  intestine.  Brieger  uses  the  term  toxin  to  designate  all 
of  the  poisonous  products  of  bacterial  action.  He  divides 
toxins  into  alkaloidal  or  crystallizable  and  amorphous,  the 
latter  being  called  toxalbumins. 

Ptomains. — By  many  writers    the    term    "ptoma'in ''   is 
used  to  designate  these  toxins,  but  in  reality  a  ptoma'in  is 
a  form  of  toxin  that  is  due  to  the  action  of  saprophytic  bac- 
teria.    A  ptoma'in  is  a  putrefactive  alkaloid,  and  a  toxin  is 
3 


34  £A CTERIOL  OG  Y. 

any  poison  of  microbic  origin.  Among  these  putrefactive  al- 
kaloids maybe  mentioned  tetanin,  typhotoxin,  sepsin,  putres- 
cin,  tyrotoxicon,  muscarin,  and  spasmotoxin.  The  poison 
which  occasionally  forms  in  cheese,  ice-cream,  sausage,  and 
canned  goods  is  composed  of  ptomains.  Poisoning  by  any 
putrid  food  is  called  ptomain-poisoning. 

I/eucotnains  must  not  be  confounded  with  the  abov^e- 
mentioned  bodies.  Leucomains  are  alkaloidal  substances 
existing  normally  in  the  tissues,  and  arising  from  phj^sio- 
logical  fermentations  or  retrograde  chemical  changes.  They 
are  natural  body-constituents,  in  contrast  to  toxins,  which 
are  morbid  constituents.  Leucomains  are  found  in  expired 
air,  saliva,  urine,  feces,  tissues,  and  the  venom  of  serpents. 
If  not  excreted,  these  bodies  may  induce  illness,  and  when 
injected  may  act  as  poisons.  Ordinary  colds  and  some  fevers 
result  from  leucomains  ;  they  play  a  great  part  in  uremia, 
and  when  excretion  is  deficient  the  retained  leucomains  make 
the  system  a  hospitable  host  for  pathogenic  bacteria.  Sick- 
ness due  to  the  retention  and  absorption  of  leucomains  is 
known  as  atitomtoxication.  Among  leucomains  may  be 
mentioned  adenin,  hypoxanthin,  and  xanthin,  allied  to  uric 
acid,  and  other  substances  allied  to  creatin  and  creatinin. 
The  surgeon  should  never  forget  the  possibility  of  harm 
being  done  by  retained  leucomains,  and  should  endeavor  to 
prevent  autointoxication  in  all  cases  by  keeping  the  skin,  the 
bowels,  and  the  kidneys  active. 

Alexins  and  Antitoxins. — Another  group  of  substances 
which  may  arise  from  microbic  action  are  known  as  "  anti- 
toxins." \Mien  a  person  suffers  from  a  bacterial  malad}'  the 
toxins  of  the  bacteria,  by  acting  upon  the  bod3'-cells,  espe- 
cially upon  the  leukocytes,  cause  the  body-cells  to  produce 
a  product  which  may  kill  the  bacteria  (alexin)  or  may  simply 
antagonize  the  toxin  (antitoxin).  It  is  taught  by  some  that 
these  materials  may  exist  in  blood-serum  as  leucomains, 
or  may  be  toxins  or  toxalbumins  absorbed  b}-  the  blood 
from  an  area  of  bacterial  disease.  It  is  a  Avell-recognized 
fact  in  fermentation  that  after  a  time  the  process  ceases, 
and  the  addition  of  more  ferment  is  \-oid  of  result.  The 
same  is  true  of  specific  maladies;  thus,  if  a  person  recovers, 
the  organisms  disappear  and  the  injection  of  more  of  them 
produces  no  result ;  in  other  words,  immunity  exists 
toward  the  disease.  This  immunity  was  long  believed 
to  arise  from  the  exhaustion  of  some  unknown  constituent 
of  tissue  necessary  to  the  life  of  the  bacteria.  It  is  now 
believed  to  be  due  partly  to  the  capacit}'  of  the  body-cells 


PHAGOCYTES.  35 

to  destroy  germs,  and  partly  to  the  production  of 
alexins  or  antitoxins,  which,  when  they  have  developed  in 
sufficient  amount,  destroy  the  bacteria  or  render  bacterial 
products  harmless.  In  other  words,  bacteria  not  only  pro- 
duce poisons,  but  also  the  antidotes  for  them.  Roux  main- 
tains that  an  antitoxin  is  not  derived  from  a  toxin,  but  that  a 
toxin  stimulates  the  body-cells  to  secrete  an  antitoxin.  He 
further  shows  that  an  antitoxin  does  not  destroy  a  toxin,  but 
acts  upon  the  body-cells  and  renders  them  capable  of  with- 
standing the  poison.  Buchner  believes  that  the  reason  the 
leukocytes  help  to  ward  off  disease  is  not  because  they  act 
as  phagocytes  to  bacteria,  but  because  they  furnish  defensive 
proteids  (alexins  or  antitoxins).  Vaughan  and  others  have 
proved  that  blood-serum  is  germicidal ;  that  the  germicidal 
agent  is  dissolved  in  the  alkaline  serum  ;  that  this  agent  is  a 
nuclein  which  is  furnished  by  the  Avhite  cells,  and  this  nuclein 
may  be  extracted  and  used  therapeutically.  Many  observers 
are  endeavoring  to  find  the  antitoxin  of  each  microbic  dis- 
ease for  the  purpose  of  applying  it  therapeutically.  Great 
claims  are  made  as  to  the  value  of  the  antitoxins  of  diph- 
theria, tetanus,  and  suppurations. 

Phagocytes. — The  tendency  of  the  white  blood-cells,  and 
in  a  less  degree  of  the  endothelial  cells  of  the  vessels,  to 
destroy  organisms  is  undoubted.  This  process  of  destruc- 
tion is  known  as  "  phagocytosis,"  and  the  destroying  cells 
are  called  "  phagocytes."  When  infection  occurs  the  Avhite 
blood-cells  gather  in  enormous  numbers  at  the  seat  of  dis- 
ease, encompass  and  surround  the  bacteria,  and  build  a  bar- 
rier to  prevent  dissemination  of  the  microbes  and  general 
infection  of  the  organism.  The  force  which  draws  leukocytes 
to  a  region  of  infection,  also  tends  to  draw  them  to  an  area 
where  there  is  cellular  degeneration  or  death.  This  force  is 
called  positive  chemiotaxis.  In  very  virulent  infections  the 
leukocytes  may  fail  to  collect  and  may  actually  be  repelled 
and  scattered  under  the  influence  of  what  has  been  called 
negative  chemiotaxis.  Phagocytes  at  the  seat  of  infection 
try  to  eat  up,  carry  aw^ay,  and  destroy  bacteria.  A  battle- 
royal  occurs,  the  microbes  fighting  the  body-cells  with  most 
active  ferments ;  the  body-cells  endeavoring  to  devour 
and  destroy  the  bacteria  (Fig.  10).  In  some  cases  the 
bacteria  win  absolutely  and  the  patient  dies.  In  other 
cases  they  win  for  a  time  and  overwhelm  the  organism  ;  but 
presently  the  body-cells,  whose  movements  were  inhibited 
by  the  poison,  regain  their  activity  and  successfully  recur  to 
the  attack.     It  is  probable  that  the  ferments  thrown  out  by 


36 


BACTERIOLOGY. 


the  white  cells  tend  both  to  kill  bacteria  and  to  neutralize 
their  toxic  products.  Those  which  kill  bacteria  are  known 
as  alexins,  and  those  which  neutralize  toxic  products  are 
known  as  antitoxins.  After  the  attack  of  disease  has  passed 
away  the  body-cells  have  been  educated  to  withstand  this 
poison,  and  new  cells  in  the  future  retain  this  capacity ;  the 
weak  cells  were  killed,  the  fittest  survived.  The  new  cells 
formed  by  the  organism  are  insusceptible  to  the  poison  and 
the  individual  is  said  to  be  immune.  This  insusceptibility, 
or  immunity,  lasts  for  a  varying  period.  Some  persons 
seem,  from  birth,  immune  to  certain  maladies.  The  theory 
of  phagocytosis  immunity  assumes  an  educated  white  cor- 


FlG.  lo. — Phagocytosis:  ^.successful;  ^,  unsuccessful  (Senn). 


puscle  and  body-cell.     This  view  originated  with  Sternberg, 
but  it  is  usually  accredited  to  Metschnikoff.     Lankester  gave 
us  the  term  "  educated  corpuscle." 
Protective    and    Preventive    Inoculations.  —  Our 

knowledge  of  protective  inoculations  for  contagious  dis- 
eases dates  from  Jenner's  discovery  in  1796.  Preventive 
inoculations  with  attenuated  virus  are  due  to  the  experi- 
ments of  Pasteur.  This  observer  discovered  the  cause  of 
chicken-cholera,  and  cultivated  the  micro-organism  of  this 
disease  outside  the  body.  He  found  that  by  keeping  his 
cultures  for  some  time  they  became  attenuated  in  virulence, 
and  that  these  attenuated  cultures,  inoculated  in  fowls,  caused 
a  mild  attack  of  the  disease,  which  attack  was  protective, 
and  rendered  the  fowl  immune  to  the  most  virulent  cult- 
ures. Cultures  can  be  attenuated  by  keeping  them  for 
some  time,  by  exposing  them  for  a  short  period  to  a  tem- 
perature just  below  that  necessary  to   kill  the  organisms, 


PROTECTIVE  AND   FREVEXTIVE   IXOCULATIOXS.      37 

or  by  treating  them  with  certain  antiseptics.  It  has  further 
been  shown  that  injection  of  the  blood-serum  of  an 
animal  rendered  immune  b}"  inoculation  is  capable  of  making 
a  susceptible  animal  also  immune. 

A  most  important  fact  is  that  animals  ma\-  be  rendered 
immune  to  certain  diseases  by  inoculating  them  \\\\\\  filtered 
cultures  of  the  microbes  of  the  disease,  the  filtrate  contain- 
ing microbic  products,  but  not  living  microbes.  By  this 
method  animals  can  be  rendered  immune  to  tetanus  and 
diphtheria.  Pasteur's  protective  inoculations  against  h}'dro- 
phobia  owe  their  power  to  microbic  products,  and  Koch's 
lymph  contains  them  as  its  active  ingredients.  The  chief 
feature  in  acquired  immunity  is  the  presence  in  the  blood  and 
tissues  of  elements  which  can  neutralize  the  toxic  products 
of  or  which  can  kill  bacteria.  These  elements  are  "  antitox- 
ins "  and  "  alexins."  The  knowledge  of  them  arose  from 
the  discover}^  of  Xuttall  and  Buchner  that  fresh  blood- 
serum  is  germicidal,  the  power  var}'ing  for  different  bacteria 
and  being  limited.  A  fixed  amount  of  serum  is  capable  of 
destroying  a  fixed  number  of  bacteria  onh'.  It  has  been 
said  that  in  tetanus  injections  of  the  serum  of  an  immune 
animal  ma}'  cure  the  disease.  The  above  facts  are  of  im- 
mense importance,  for  on  these  lines  may  be  solved  the  prob- 
lems of  the  prevention  and  treatment  of  microbic  maladies. 

Orrhotherapy,  or  serum-therap\',  is  an  attempt  to  utilize 
therapeutically  the  germicidal  properties  of  blood-serum. 
It  is  believed  that  when  a  man  gets  an  infectious  disease 
the  toxins  act  upon  the  body-cells  and  cause  the  formation 
by  these  cells  of  defensive  proteids,  alexins,  curative  nucleins, 
or  antitoxins.  These  products  enable  the  bod}--cells  to  with- 
stand further  injur}'  b}'  the  toxins,  the  disease  comes  to  an 
end,  the  bacteria  die,  and  the  alkaline  blood-serum  is  satu- 
rated with  protective  material.  If  the  above  facts  are  true,  it 
is  an  eas}'  deduction  that  blood-serum  containing  protective 
material  should  cure  the  disease  if  injected  into  a  patient  suf- 
fering from  an  attack.  Instead  of  using  the  blood-serum 
itself,  some  observers  have  precipitated  the  curative  nuclein 
from  the  serum,  and  used  the  nuclein  in  solution  in  fixed 
amounts.  Instead  of  using  the  serum  of  persons  rendered 
immune  b}-  an  attack  of  the  disease,  man}-  ph}"sicians  have 
employed  the  serum  of  animals  rendered  artificial!}*  immune 
b}'  injections  of  attenuated  cultures  of  the  bacteria.  Some 
experimenters  haveemplo}'ed  even  the  serum  of  animals  nat- 
urally immune  to  the  disease.  That  Pasteur  has  devised  a 
method  which  will   usualh*  prevent  h}-drophobia  is  certain 


38  BACTERIOLOGY. 

(page  233),  and  that  Murri,  of  Bologna,  has  cured  a  case  of 
hydrophobia  seems  proved  (page  234).  Hosts  of  observers 
believe  in  the  utility  of  tetanus  antitoxin  and  diphtheria 
antitoxin. 

Inconclusive  experiments  have  been  made  in  the  treat- 
ment of  syphilis  by  the  serum  of  dog's  blood,  and  by  the 
blood-serum  of  men  laboring  under  tertiary  syphilis  ;  in  the 
treatment  of  pneumonia  with  the  blood-serum  of  persons  con- 
valescent from  pneumonia ;  and  in  the  treatment  of  sufferers 
from  septic  diseases  with  antistreptococcic  serum — blood- 
serum  of  animals  rendered  immune  to  septic  infections.  Ma- 
lignant tumors  (both  sarcomata  and  carcinomata)  have  been 
treated  with  the  blood-serum  of  dogs,  which  animals  had 
been  injected  with  fluid  expressed  from  malignant  growths 
(Richet  and  Hericourt.)  Many  claims  made  for  serum- 
therapy  in  surgical  diseases  are  exaggerated,  sensational, 
and  unscientific.  That  there  is  truth  in  the  method  seems 
highly  probable,  but  how  much  of  it  is  true  is  not  yet  defi- 
nitely ascertained.  It  is  our  duty  to  study,  experiment,  and 
observe,  and  to  reach  a  conclusion  only  after  honest,  careful, 
and  thorough  investigation.  A  little  skepticism  is  as  yet  a 
safe  rule. 

Antagonistic  Microbes. — Another  observation  of  im- 
portance is  that  certain  microbes  are  antagonistic  to  one 
another.  The  streptococcus  of  erysipelas  attacks  the  or- 
ganism of  anthrax,  and  is  antagonistic  to  several  infectious 
diseases  (syphilis  and  tuberculosis),  also  to  sarcoma.  We 
should  note  also  that  the  growth  of  some  microbes  affects 
culture-media  favorably  or  otherwise  for  the  growth  of  other 
organisms,  and  the  same  may  be  true  in  the  tissues  of  the 
human  body.  It  is  not  yet  proper  to  endeavor  to  cure  a 
microbic  disease  by  inoculating  antagonistic  microbes,  on 
the  principle  of  sending  a  thief  to  catch  a  thief 

Mixed  Infection. — A  fact  of  practical  importance  to 
the  surgeon  is  that  an  area  infected  by  one  form  of  patho- 
genic organism  may  be  invaded  by  another  form.  This  is 
known  as  a  mixed  \x\{qc'{\ox\,  and  consists  of  2i  primary  infec- 
tion with  one  variety  of  organism,  and  a  secondary  infection 
with  another,  or  in  an  infection  at  the  same  time  with  differ- 
ent micro-organisms.  Koch  found  both  bacilli  and  micro- 
cocci in  the  same  lesion  of  tubercle.  A  soil  filled  with 
pneumococci  favors  the  growth  of  pus  cocci  and  tubercle 
bacilli.  Tubercular  or  syphilitic  lesions  may  be  attacked 
by  erysipelas.  Chancre  and  chancroid  can  exist  together, 
A  syphilitic  ulcer  is  a  good  culture-soil  for  tubercle  bacilli 


SPECIAL    SURGICAL   MICROBES. 


39 


(Schnitzler).  Suppuration  in  lesions  of  tuberculosis  is  due 
to  secondar)^  infection  with  pus  organisms. 

Placental  Transmission. — The  direct  transmission  of 
bacteria  from  parent  to  fetus  is  a  problem  still  in  course  of 
solution.  Certain  it  is  that  some  diseases  (as  syphilis)  are 
due  to  the  direct  carr\-ing  of  the  microbes  by  sperm-cell  to 
germ-cell,  or  to  the  transmission  of  the  micro-organism 
through  the  septum  of  separation  between  the  circulations 
of  the  mother  and  child.  In  many  other  diseases  the  mi- 
crobe is  not  directly  transmitted  (as  in  phthisis),  but  a  patient 
born  with  weakened  tissue-cells  is  prone  to  fall  a  prey  to  the 
latter  malady. 

Special  Surgical  Microbes. — Suppuration  is  caused  by 
microbes.  Can  it  exist  without  them  ?  The  answer  is,  No. 
Injection  of  a  fluid  containing  dead  organisms  will  form  a 
limited  amount  of  pus  ;  injection  of  an  irritant  forms  a  thin  fluid 
which  may  resemble  pus,  but  which  is  not  pus.  In  surgery 
pus  is  not  met  with  without  the  micro-organisms,  and  the 
presence  of  pus  proves  the  presence  of  micro-organisms. 
Pus  uiicrobt's,  or  pyogenic  inici-obcs,  possess  the  propert}'  of 
peptonizing  albumin,  and  thus  forming  pus.  The  peptonizing 
action  is  brought  about  by  bacterial  proteids,  or  ferments. 
The  inflammation  which  surrounds  an  area  of  pyogenic  in- 


FiG.  II. — Staphylococcus  pyogenes  aureus 
in  pus  (X  looo)  (Frankel  and  Pfeiffer). 


Fig.    12. — Streptococcus    pyogenes   in 
pus  (X  looo)  (Frankel  and  Pfeiffer). 


fection  is  caused  by  the  irritant  products  of  bacterial  action 
(toxalbumins,  ammonia,  etc.).  In  the  presence  of  the  pyo- 
genic peptones  the  coagulation  of  inflammator}'  exudate  is 
retarded  or  prevented.  The  most  usual  causes  of  suppura- 
tion are  the  following  micro-organisms  : 

Staphylococcus pyogaus  aureus  (Plate  I,  Fig.  I,  and  Fig.  1 1), 
the  golden-yellow  coccus.  This  is  the  most  usual  cause  of 
abscesses  (circumscribed  suppurations);  yy  per  cent,  of  acute 


40  BACTERIOLOGY. 

abscesses  are  due  to  staphylococci  (W.  Watson  Cheyne). 
Staphylococci  are  found  also  in  osteomyelitis.  The  staphy- 
lococcus pyogenes  aureus  is  a  facultative  anaerobic  parasite 
which  is  widely  distributed  in  nature,  and  is  found  in  the 
soil,  the  dust  of  air,  water,  the  alimentary  canal,  under  the 
nails,  on  and  in  the  superficial  layers  of  skin,  especially  in 
the  axillae  and  perineum.  It  forms  the  characteristic  color 
only  when  it  grows  in  air.  It  is  killed  in  ten  minutes  by  a 
moist  temperature  of  58°  C,  and  is  instantly  killed  by  boiling 
water.  Carbolic  acid  (i  :  40)  and  corrosive  sublimate 
(i  :  2000)  are  quickly  fatal  to  these  cocci. 

Staphylococcus  pyogenes  albus  (Plate  i,  Fig.  2),  the  white 
staphylococcus,  acts  like  the  aureus,  but  is  more  feeble  in 
power.  When  this  organism  is  found  upon  and  in  the  skin 
it  is  called  the  staphylococcus  epidermidis  albus,  an  organism 
which  Welch  proved  to  be  the  usual  cause  of  stitch-abscesses. 

Staphylococcus  pyogenes  citreiis,  the  lemon-yellow  coccus, 
is  found  occasionally  in  acute  circumscribed  suppurations, 
but  far  more  rarely  than  the  other  two  forms.  Its  pyogenic 
power  is  even  weaker  than  that  of  the  albus. 

Staphylococcus  cei'eus  albus,  is  found  occasionally  in  acute 
abscesses. 

Staphylococcus  cereus  flavus  is  found  occasionally  in  acute 
abscesses. 

Staphylococcus  flavcscens  is  occasionally  found  in  abscesses. 
Is  intermediate  between  the  aureus  and  albus  (Senn). 

Micrococcus  pyogenes  tenuis  rarely  takes  the  form  of  a 
bunch  of  grapes.  Is  occasionally  found  in  the  pus  of  acute 
abscesses. 

Streptococcus  pyogenes  (Fig.  12)  is  found  in  spreading  sup- 
puration. Woodhead  tells  us  (Treves'  System  of  Sanger}')  that 
six  organisms,  each  of  which  bears  a  separate  name,  are  dis- 
cussed under  this  designation.  Three  of  these  organisms  he 
places  in  one  group,  two  in  another,  and  says  the  sixth  may 
be  a  separate  species. 

1st  Group. — Streptococcus  pyogenes,  found  especially  in 
spreading  suppuration  and  in  very  acute  abscesses.  Cheyne 
says  that  16  per  cent,  of  acute  abscesses  contain  streptococci. 
Is  easily  killed  by  boiling,  and  can  be  destroyed  by  carbolic 
acid  and  corrosive  sublimate.  Exists  normally  in  the  nasal 
passages,  vagina,  mouth,  and  urethra. 

Streptococcus  pyogenes  vialignus,  an  uncommon  organism 
found  in  splenic  abscess. 

Streptococcus  septicus  has  a  strong  tendency  to  break  up 
into  diplococci. 


BACTERIOLOGY, 


Plate  i. 


1.  Staphylococcus  pyogenes  aureus. 

2.  Staphylococcus  pyogenes  albus. 

3.  Bacillus  tuberculosis  on  glycerin-agar. 

(Warren's  Surgical  Pathology. ) 


SURGICAL    MICROBES 


41 


2d  Group. — Streptococcus  of  erysipelas,  found  in  capillary 
lymph-spaces  in  erysipelas.  Many  bacteriologists  believe  it 
to  be  identical  with  the  streptococcus  pyogenes. 

Streptococcus  of  Septicemia  and  Pyemia. — Most  observers 
maintain  that  it  is  identical  with  the  streptococcus  pyogenes 
and  streptococcus  of  erysipelas. 

3d  Group. — Streptococcus  articiilonnn,  found  in  false  mem- 
brane of  diphtheria  (see  the  article  by  Woodhead  in  the 
System  of  Surgery  by  Frederick  Treves). 

The  micrococcus  teirageiuis  is  thought  to  be  the  bacterium 
chiefly  responsible  for  the  suppuration  of  tubercular  pul- 
monary lesions. 

Bacillus  pyogenes  fvtidus,  found  especially  in  the  pus  of 
ischiorectal  abscesses. 

Bacillus  pyocyaneiis,  found  by  Ernst  in  blue  pus. 

The  gonococcus,  the  pneumococcus,  the  baciUus  of  typhoid 
fever,  and  the  colon  bacillus  have  pyogenic  power. 

Other  Surgical  Microbes. — Streptococcus  of  erysipelas 
(Fehleisen's  coccus),  as  stated  before,  is  thought  by  many  to 
be  identical  with  the  strepto- 
coccus pyogenes.  Their  differ- 
ence in  action  is  believed  by 
Sternberg  to  be  due  to  differ- 
ence in  virulence  induced  by 
external  conditions  and  by  the 
state  of  the  tissues  of  the  host. 
The  coccus  of  erysipelas  is 
somewhat  larger  than  the 
ordinary  form  of  streptococcus 
pyogenes.  Infection  takes  place 
by  a  wound,  often  a  very 
trivial  wound  of  the  skin  or  mu- 
cous membrane.  The  organism 
multiplies  in  the  small  lymph- 
channels.  This  organism  will 
cause  puerperal  fever  in  a 
woman  in  childbed  when  it 
gains  access  to  "  an  absorbing 

surface  in  the  genital  tract "  (Senn).  The  streptococcus  may 
cause  suppuration  in  erysipelas,  mixed  infection  not  being 
necessary  to  induce  pus  formation. 

The  gonococcjis  (Fig.  14,  the  bacillus  of  Neisser),  the  dip- 
lococcus  which  causes  gonorrhea.  Bumm  proved  the" 
causative  influence  of  the  gonococcus.  He  reproduced 
the  disease  in  a  healthy  female  urethra  by  inoculation  with 


Fig.  13. — Anthrax  bacilli  in  blood 
( Vierordt). 


42  BACTERIOLOGY. 

the  twentieth  generation  in  descent  from  a  pure  culture. 
Diplococci  are  found  often  in  the  secretions  of  apparently 
healthy  mucous  membranes,  and  simulate  very  closely  gono- 
cocci.  Gonococci  cannot  be  cultivated  upon  ordinary  media, 
but  grow  best  upon  human  blood-serum.  In  gonorrhea  the 
organisms  are  found  both  within  and  outside  of  pus-cells  and 


Fig.  14. — Gonococci  from  gonorrheal  pus. 


mucus-cells.  It  seems  reasonably  certain  that  the  gono- 
coccus  is  pyogenic,  although  it  is  possible  that  the  pus 
formed  in  gonorrhea  is  due  to  mixed  infection.  Gonococci 
stain  easily  and  are  readily  decolorized  by  Gram's  method. 


Fig.  15. — Bacillus  of  tetanus,  with  spores. 

Streptococci  are  found  in  noma.  No  specific  organism  has 
been  isolated  for  traumatic  spreading  gangrene  or  hospital 
gangrene. 

The  bacillus  tetanus  (Fig.  15,  Nicolaier's  bacillus),  an  an- 
aerobic organism,  found  especially  in  the  soil  of  gardens,  in 
the  dust  of  old  buildings,  in  street  dirt,  and  in  the  sweepings 


SURGICAL    MICROBES. 


43 


of  stables.  Spores  develop  at  the  ends  of  these  bacilli. 
The  bacilli  are  capable  of  producing  toxins  of  deadly  power. 
The  spores  are  very  resistant  and  it  is  difficult  to  kill  them. 
The  drug  which  is  most  certainly  fatal  to  tetanus  bacilli  is 
bromin. 

The  bacillus  tuberculosis  (Koch's  bacillus,  Plate  i,  Fig.  3), 
the  cause  of  all  tubercular  processes,  is  met  with  especially 
in  dusty  air  which  contains  the  dried  sputum  of  victims  of 
phthisis.  This  infected  air  is  the  chief  means  of  transmission 
of  the  disease,  though  it  may  be  conveyed  by  the  milk  of 
tubercular  cows  and  the  meat  of  tubercular  animals. 
Wounds  may  open  a  gateway  for  infection.  Fig.  16  shows 
tubercle  bacilli  in  sputum. 


-T, 

t 

U    \ 

'       '  ,,, 

^ 

\ 

\K 

V 

\  ^_^ 

Z'; 

-'^ 

vs 

r 

^' 

_ 

^\ 

/*" 

^ 

'•^V        X 

\ 

J 

\ . 

•T*        \^ 

s    ^        '^ 

Fig.  16. — Tubercle  bacilli  in  sputum  (Ziegler). 

Bacillus  anthracis  (Fig.  13),  the  cause  of  malignant  pus- 
tule, or  splenic  fever. 

Bacillus  juallei,  the  cause  of  glanders. 

Bacilkis  of  syphilis  (Lustgarten's  bacillus).  That  syphilis 
is  due  to  a  micro-organism  is  highly  probable,  but  that  we 
have  found  the  causative  organism  in  Lustgarten's  bacillus 
is  by  no  means  sure.  A  fact  which  points  strongly  against 
its  causative  power  is  that  it  is  found  rather  in  non-contagious 
tertiary  lesions  than  in  contagious  secondary  lesions. 

Diplococcus  pncumonice  is  believed  to  be  the  cause  of  pneu- 
monia and  acute  meningitis.  It  is  found  normally  in  the 
human  saliva.  This  organism  is  often  spoken  of  as  Frankel's 
bacillus  and  also  as  the  diplococcus  lanceolatus. 

The  bacilhis  coli  covnminis,  called  also  the  bacterium  coli 
commune  or  the  bacillus  of  Escherich  (Fig.  17).  Feces 
invariably  contain  this  organism.  It  is  believed  by  many 
observers  to  be  the  cause  of  appendicitis,  peritonitis,  abscesses 
about  the  intestine,  many  ischiorectal  abscesses,  some  peri- 


44  ^AC  TERIOL  OGY. 

renal  abscesses,  certain  cases  of  cystitis,  cholangitis,  and 
cholecystitis.  In  cases  of  appendicitis  we  can  get  a  pure 
culture  of  Escherich's  bacillus,  but  usually  find  also  strepto- 
cocci, staphylococci,  or  pneumococci.  The  colon  bacillus 
has  pyogenic  power. 

The  bacillus  of  malignant  cdcnia  (the  vibrione  septique 
of  Pasteur),  found  especially  in  stagnant  water  and  certain 
varieties  of  soil.  In  the  disease  known  as  malignant  edema 
there  is  a  mixed  infection  with  the  bacilli  of  malignant  edema 
and  saprophytic  organisms,  and  the  latter  form  considerable 
quantities  of  gas  in  the  tissues.  The  bacilli  of  malignant 
edema  may  cause  spreading  gangrene. 


X  t 

J'i 

,X'S^ 

-'"  r 

^'1 

h^ 

\_ 

f     4 

4 

V-            u 

•                       « 

\ 

/r' 

"<.      ^        ^ 

-jr    ^      ^ 

<€ 

'"     V  ,,, 

t:    ^< 

Fig.  17. — Bacillus  coli  communis. 

The  bacillus  of  typhoid  fever  (Eberth's  bacillus)  is  respon- 
sible for  some  cases  of  gangrene,  some  of  embolism,  and  not 
a  few  of  bone  and  joint  disease.     It  has  pyogenic  power. 

We  may  mention,  in  conclusion,  as  of  occasional  surgical 
importance,  the  bacillus  of  influenza,  bacillus  of  diphtheria, 
bacillus  of  bubonic  plague,  bacillus  of  leprosy,  bacillus  of 
rhinoscleroma,  bacillus  of  fetid  ozena,  bacillus  of  hemor- 
rhagic septicemia,  bacillus  lactis  aerogenes  (an  occasional 
cause  of  peritonitis),  and  the  bacillus  aerogenes  capsulatus. 
The  later  organism  causes  gangrenous  cellulitis,  a  spreading 
gangrene  accompanied  by  gas  formation. 

The  putrefactive  organisms  are  responsible  for  many  septic 
intoxications. 


ASEPSIS  AXD   ANTISEPSIS.  45 

II.  ASEPSIS  AND  ANTISEPSIS. 

The  effort  in  all  operations  is  to  secure  and  maintain 
scrupulous  surgical  cleanliness.  What  is  known  as  the  anti- 
septic method  we  owe  to  the  splendid  labors  of  Lord  Lister, 
and  the  aseptic  method  is  but  a  natural  evolution  of  the  anti- 
septic method.  Lister  called  the  attention  of  the  profession 
to  a  new  method  of  treating  wounds,  compound  fractures, 
and  abscesses  in  1867.'  The  processes  first  employed  were 
extremely  complicated,  but  have  been  made  in  the  last  few 
years  simple  and  easy  of  performance.  Lister  believed  the 
chief  danger  to  be  from  air.  It  is  now  believed  that  the 
chief  danger  is  from  actual  contact  of  hands,  instruments, 
dressings,  or  foreign  bodies  with  a  wound.  Air  carries  but 
few  micro-organisms  unless  it  is  filled  with  dust.  Infection 
through  air  is  most  apt  to  occur  if  the  air  is  dusty,  and  is 
more  common  after  an  aseptic  than  an  antiseptic  operation. 

Of  course,  some  bacteria  from  the  air  must  settle  in  every^ 
wound,  but  the  majority  of  air  fungi  are  harmless.  Com- 
paratively few  reach  the  wound  unless  the  air  is  dust}',  and 
these  few  the  tissues  are  usually  able  to  destroy.  Schimmel- 
busch  made  experiments  in  von  Bergmann's  clinic  when  the 
students  were  present.  He  found  that  "  the  number  of  bac- 
teria which  settle  upon  the  surface  of  a  wound  a  square  deci- 
meter in  extent,  in  the  course  of  half  an  hour,  is  about  60  or 
70,"  and  thousands  are  usually  required  to  produce  infection. . 

There  is  no  danger  of  the  breath  alone  producing  infec- 
tion. Air  which  comes  from  the  lungs  is  germ-free,  and  even 
a  large  class  will  not  infect  the  air  by  breathing,  but  will 
rather  help  free  it  from  bacteria,  for  the  lungs  are  filters  for 
air  laden  with  micro-organisms.  Mikulicz  believes  that  the 
surgeon  in  talking,  coughing,  etc.,  is  apt  to  project  infective 
particles  into  the  wound,  and  so  he  advises  the  wearing  of  a 
respirator  over  the  mouth. 

Surgical  cleanliness  may  be  obtained  by  either  the  aseptic 
or  the  antiseptic  method.  In  the  aseptic  method  heat, 
chemical  germicides,  or  both  are  used  to  cleanse  the  instru- 
ments, the  field  of  operation,  and  the  hands  of  the  surgeon 
and  his  assistants,  the  surface  being  freed  from  the  chemical 
germicide  by  washing  with  boiled  water  or  with  saline  solu- 
tion. After  the  incision  has  been  made  no  chemical  germi- 
cide is  used,  the  wound  being  simply  sponged  with  gauze 
sterilized  by  heat ;  if  irrigation  is  necessary,  boiled  water  or 
normal  salt  solution  is  used,  and  the  wound  is  dressed  with 
gauze  which  has  been  rendered  sterile  by  heat.     The  effort 

'  The  Lancet. 


46  ASEPSIS  AND  ANTISEPSIS. 

of  the  surgeon  is  simply  to  prevent  the  entrance  of  micro- 
organisms into  the  tissues.  Some  micro-organisms  must 
enter,  but  the  number  will  be  so  small  that  healthy  tissues 
will  destroy  them.  The  aseptic  method  should  be  used 
only  in  non-infected  areas.  If  chemical  germicides  are  not 
used,  the  amount  of  wound-fluid  will  be  small  and  the  sur- 
geon can  often  dispense  with  drainage.  If  a  wound  is  to 
be  closed  without  drainage,  every  point  of  bleeding  must 
be  ligated.  It  is  often  advisable  to  sew  up  the  wound 
with  Halsted's  subcuticular  stitch.  If  this  stitch  is  em- 
ployed, the  skin  staphylococcus  does  not  obtain  access  to 
stitch-holes  and  stitch-abscesses  are  not  apt  to  arise.  This 
suture  may  consist  of  catgut,  silk,  or,  preferably,  silver  wire, 
this  latter  agent  being  capable  of  certain  sterilization  by  heat 
and  exercising  a  powerful  inhibitory  action  on  micro-organ- 
isms. If  a  wound  is  closed  without  drainage,  firm  compres- 
sion is  applied  over  the  wound  to  obliterate  any  cavity  which 
may  exist.  In  some  regions  of  the  body  wounds  are  sealed 
with  collodion  or  iodoform-collodion.  If  irrigation  is  not 
practised  and  the  wound  is  dressed  with  dry  sterile  gauze, 
the  procedure  is  said  to  be  by  the  "  dry  "  aseptic  method.  In 
the  antiseptic  method  the  same  preparations  are  made  for  the 
operation  as  in  the  aseptic  method,  but  during  the  operation 
sponges  impregnated  with  a  chemical  germicide  are  used, 
and  the  wound  is  dressed  with  gauze  containing  corrosive 
sublimate  or  some  other  chemical  germicide.  If  the  wound 
is  not  flushed  with  a  chemical  germicide,  and  is  dressed  with 
dry  antiseptic  gauze,  the  operation  is  said  to  be  by  the 
"  dry  "  antiseptic  method.  The  antiseptic  method  is  preferred 
in  infected  areas.  Dry  dressings  are  usually  preferable  to 
moist  dressings,  because  they  are  more  absorbent  and  do 
not  act  as  poultices,  and  dry  dressings  may  be  used  even 
when  the  wound  has  been  flushed.  In  suppurating  areas 
it  is  often  best  to  use  moist  dressings  in  the  form  of  anti- 
septic fomentations.  Year  by  year  the  aseptic  method 
becomes  more  popular.  Surgeons  have  learned  that  the 
most  important  factor  in  asepsis  is  mechanical  cleansing  by 
means  of  soap  and  water.  The  chemical  germicide  plays  a 
secondary  rather  than  a  vital  part.  By  mechanical  cleansing 
great  numbers  of  micro-organisms  are  removed  along  with 
dirt,  grease,  and  epithelium.  Many  organisms  remain,  but 
vast  hordes  are  washed  away,  and  the  danger  of  infection  is 
greatly  lessened  by  thus  diminishing  the  number  of  organ- 
isms. If  a  chemical  germicide  is  used  without  preliminary 
mechanical  cleansing,  it  is  useless,  because  it  cannot  destroy 


PREPARATIOXS  FOR  AX  OPERATION.  47 

bacteria  in  the  epithelium  and  in  masses  of  oily  matter. 
After  the  use  of  mechanical  cleansing  the  germicide  is  active 
in  destroying  the  comparatively  few  bacteria  which  are  naked 
on  the  surface.  In  many  regions  a  strong  chemical  germi- 
cide must  not  be  used  (in  the  abdomen,  in  the  brain,  in  joints, 
in  the  pleural  sac,  and  in  the  bladder),  and  in  other  regions 
(mucous  surfaces  and  fatt>-  tissue)  it  is  productive  of  harm 
rather  than  good. 

Preparations  for  an  Operation. — A  room  in  which 
an  operation  is  to  be  performed  should  be  well  lighted  and 
well  ventilated.  It  is  advantageous  to  have  an  open  grate  in 
the  room,  for  then  a  fire  can  be  quickly  made  to  take  a  chill 
off  the  air  and  ventilation  is  improved.  The  morning  before 
the  operation  furniture  should  be  removed,  the  carpet  taken 
up.  and  curtains  and  hangings  taken  down.  If  the  ceiling 
and  walls  are  papered,  they  must  be  thoroughly  brushed.  If 
they  are  painted,  they  must  be  washed  off  with  soap  and 
water.  Dust  is  thus  removed,  and  the  danger  of  dust  falling 
into  the  wound  is  averted.  The  floor  is  scrubbed  with  soap 
and  water.  The  windows  should  be  opened  for  many  hours 
to  thoroughly  dry  and  freshen  the  room.  On  the  morning 
of  the  operation  the  patient's  bed  is  brought  into  the  room 
and  placed  in  a  position  where  there  will  be  plenty  of  light 
for  future  dressings,  and  where  the  surgeon  will  have  access 
from  either  side.  Never  use  a  big  broad  bed  ;  use  a  narrow 
bed.  Never  have  a  feather  bed,  but  insist  on  Treves's  advice 
being  followed,  and  employ  a  metal  bed  with  a  wire  netting 
and  hair  mattress. 

A  piece  of  carpet  or  rug  is  spread  upon  a  portion  of  the 
floor  and  the  table  is  set  upon  it.  The  table  should  be  so 
placed  that  there  will  be  a  good  light  on  the  field  of  opera- 
tion. A  kitchen  table  does  very  well.  On  the  table  is 
placed  a  folded  comfortable  or  several  folded  blankets. 

Around  the  operating-table  at  proper  distances  are 
arranged  a  table  for  instruments,  a  table  for  dressings, 
a  table  for  sponges  and  a  basin  of  bichlorid,  and  a  table 
for  soap  and  a  basin  of  water.  A  couple  of  buckets 
should  be  placed  on  the  floor  near  at  hand.  The  nurse  and 
assistants  should  have  ready  the  ether  cone,  wrapped  in  a 
clean  towel,  sterile  sheets,  sterile  gowns,  sterile  towels,  ster- 
ile gauze  for  sponges  and  dressings,  trays  for  instruments, 
iodoform  gauze,  catgut,  silk,  silkworm-gut.  etc.,  according 
to  the  nature  of  the  operation.  The  surgeon  should  pick 
out  the  instruments  required.  The  anesthetizer  should  lay 
out  a   mouth-gag.  tongue-forceps,  a   hypodermatic   syringe 


48  ASEPSIS  AND  ANTISEPSIS. 

in  working  order,  ether  or  chloroform,  brandy,  tablets  of 
strychnin,  and  also  of  atropin. 

The  patient  has  been  prepared  the  day  before,  except  in 
emergency  cases. 

The  surgeon  and  his  assistants  remove  their  coats,  roll  up 
their  sleeves,  and,  after  sterilizing  the  hands  and  forearms, 
envelop  their  bodies  in  aseptic  or  antiseptic  sheets  or  gowns, 
to  protect  the  patient  and  themselves.  It  is  a  good  plan  for 
the  surgeon  and  his  assistants  to  wear  sterile  muslin  caps.  The 
caps  prevent  hair,  dandruff,  and  sweat  falling  into  the  wound. 

It  is  a  difficult  or  impossible  matter  to  absolutely  sterilize 
the  hands,  but  it  is  fortunate,  as  Mikulicz  and  Flugge  say, 
that  most  of  the  bacteria  of  the  skin  are  harmless.  The 
staphylococcus  epidermidis  albus,  however,  is  constantly 
present  in  the  epidermis.  The  hands  of  some  persons  are 
more  easily  sterilized  than  those  of  others.  For  instance, 
a  hairy,  creased  hand  is  more  difficult  of  sterilization  than  a 
smooth  and  almost  hairless  one ;  a  hand  grossly  neglected 
than  one  reasonably  clean.  Germs  abound  in  the  epi- 
dermis, in  the  fissures  and  creases,  under  and  around  the 
nails,  on  hairs,  and  in  the  ducts  of  glands.  The  surface  of  the 
hands  may  be  thoroughly  sterile  at  the  beginning  of  an 
operation  and  become  infected  later,  because  germs  in  gland 
ducts  are  forced  to  the  surface.  Hence,  in  a  prolonged 
operation,  the  surgeon  should  stop  from  time  to  time  and 
wash  his  hands,  first  in  alcohol  and  then  in  corrosive  sub- 
limate solution  (Leonard  Freeman). 

In  view  of  the  difficulty  of  cleansing  the  hands,  every  stu- 
dent must  be  taught  how  to  do  it.  The  more  hands  used  in  an 
operation  the  greater  is  the  danger  of  infection  of  the  wound. 
The  surgeon's  fingers  must  enter  the  wound.  The  fingers  of 
no  other  person  should  enter  unless  absolutely  necessary. 

The  hands  and  forearms  are  sterilized  in  the  following 
manner :  Scrub  for  five  minutes  with  soap  and  hot  sterile 
water,  giving  special  attention  to  the  nails  and  creases  in  the 
skin.  The  brush  is  rubbed  in  the  long  axis  of  the  extremity 
and  also  transversely.  The  creases  on  the  back  of  the  hands 
and  fingers  will  be  partially  opened  by  flexing  the  fingers, 
and  transverse  scrubbing  will  clean  the  furrows.  The  fur- 
rows on  the  palmar  surface  will  be  opened  by  extending  the 
fingers,  and  will  be  best  cleaned  by  transverse  scrubbing  (G. 
Ben.  Johnson).  The  best  soap  is  the  ethereal  soap  of 
Johnston,  which  is  a  solution  of  castile  soap  in  ether. 
Green,  or  castile,  soap  can  be  used.  The  brush  employed 
should  be  kept  in  a  i  :  looo  solution  of  corrosive  sublimate. 


PKEPAKATIOXS  FOR  AN  OPERATION.  49 

The  nails  are  cut  short,  are  cleansed  with  a  knife,  and  the 
hands  are  again  scrubbed.  After  washing  off  the  soap  the 
hands  are  dipped  for  a  moment  in  pure  alcohol,  and  the 
forearms  are  rubbed  with  alcohol.  Alcohol  removes  the 
soap  which  has  entered  into  follicles  and  creases,  removes 
desquamated  epithelium,  enters  under  and  about  the  nails, 
and  favors  the  diffusion  of  the  corrosive  sublimate  under  the 
nails  and  into  the  follicles,  when  the  hands  are  placed  later 
in  the  mercurial  solution.  After  using  the  alcohol  the  hands 
are  then  dipped  in  a  hot  solution  of  corrosive  sublimate 
(i  :  1000),  and  with  the  forearms  are  scrubbed  for  at  least  a 
minute,  the  nails  receiving  especial  care.  Kelly  disinfects 
the  hands  by  washing  them  with  soap  and  water,  dipping 
them  in  a  solution  of  permanganate  of  potassium  (a  saturated 
solution  in  distilled  water),  and  decolorizing  them  in  a 
saturated  solution  of  oxalic  acid  and  washing  off  the  oxalic 
acid  in  sterile  water. 

Weir  has  highly  commended  the  following  plan,  and  Stim- 
son  is  also  pleased  with  it :  Scrub  the  hands  with  a  brush 
and  green  soap  and  in  running  hot  water.  Clean  under  the 
nails  with  a  piece  of  soft  wood.  Place  about  a  tablespoonful 
of  chlorinated  lime  in  the  palm  of  the  hand,  place  upon  the 
lime  an  equal  amount  of  cry^stalline  washing-soda,  add  a 
little  water,  and  rub  the  creamy  mixture  over  the  arms  and 
hands  until  the  rough  granules  of  sodium  carbonate  are  no 
longer  felt.  Place  the  paste  under  and  around  the  nails  by 
means  of  a  bit  of  sterile  orange  wood.  Wash  the  arms 
and  hands  in  hot  sterile  water.^  The  combination  forms 
nascent  chlorine,  a  most  efficient  germicide.  This  method 
has  proved  most  satisfactorv'  in  the  clinic  of  the  Jefferson 
Medical  College  Hospital.  It  is  important  that  crj^stalline 
washing-soda  be  employed.  If  the  bicarbonate  is  used, 
nascent  chlorine  will  not  be  produced,  but  h}-drochloric  acid 
gas  will  be  formed,  and  the  latter  gas  irritates  the  skin  and 
is  not  a  satisfactory  germicide. 

Some  surgeons  are  so  impressed  with  the  impossibility'  of 
sterilizing  the  hands  that  they  wear  gloves  in  operations. 
Hunter  Robb  suggested  the  use  of  gloves  in  1894.  ]\Iiku- 
licz  used  white  cotton  gloves.  Lockett  has  proved  that 
cotton  and  silk  are  not  imper\dous  to  micro-organisms,  but 
that  rubber  is.  The  thin,  seamless  rubber  gloves  which  are 
now  made  are  very  satisfactory'.  The}'  are  sterilized  by 
boiling,  are  then  dried,  and  are  wrapped  in  a  sterile  towel. 
In  order  to  insert  the  hand  in  them,  the  interior  of  the  glove 

^  Medical  Record,  April  3,  1897. 


50 


ASEPSIS  AND   ANTISEPSIS. 


should  be  first  dusted  with  sterile  starch  or  talc  powder,  and 
then  the  nurse  should  hold  the  glove  while  the  surgeon 
inserts  his  fingers  into  the  proper  compartments  and  pushes 
the  hand  in. 

If,  during  an  operation,  a  glove  becomes  infected,  a  clean 
one  can  be  substituted  for  it.  Gloves  somewhat  impair  the 
sense  of  touch,  but  a  surgeon  soon  learns  to  work  with 
them.  If  they  are  to  be  used,  the  hands  should  be  sterilized 
just  as  carefully  as  when  they  are  not  to  be  used,  because, 
during  the  operation,  the  gloves  may  tear  or  be  punctured 
by  a  needle.  That  it  is  absolutely  necessary  to  wear  gloves 
in  all  cases  has  not  been  proved.  Their  use  does  contrib- 
ute to  success  in  brain  operations,  abdominal  operations, 
and  joint-operations.  They  are  of  great  value  in  military 
surgery. 

When  a  surgeon  is  obliged  to  place  his  fingers  in  an  area 
of  virulent  infection  he  may  be  poisoned.  Gloves  will  save 
him  from  this  danger.  Again,  a  surgeon  should  try  to  avoid 
bringing  his  hands  unnecessarily  in  contact  with  putrid  or 
purulent  matter.  Though  it  may  not  poison  him,  it  grossly 
infects  the  surface,  renders  subsequent  cleansing  difficult, 
and  endangers  other  patients.  Gloves  will  prevent  this 
danger.  A  surgeon  should  wear  gloves  if  he  is  making  an 
examination  or  performing  an  operation  which  is  sure  to 
infect  grossly  the  bare  hands,  and  he  should  wear  gloves  in 
an  operation  if  in  a  previous  operation  his  hands  were  grossly 
infected. 

Instruments  are  disinfected  by  boiling  for  fifteen  minutes 
in  a  I  per  cent,  solution  of  carbonate  of  sodium  and   then 

rinsing  them  in  a  5  per  cent, 
solution  of  carbolic  acid  or  in 
sterile  water.  The  carbonate 
of  sodium  prevents  rusting. 
In  a  clinic  the  boiling  is  car- 
ried out  in  a  Schimmelbusch 


Fig. 


-Schimmelbusch's  gas-heated  apparatus  for  sterilizing  instruments  : 
b,  wire  basket. 


sterilizer  (Fig.    18).       In   a   private   house    it    can    be    done 
in  a  sterilizer  such  as  that  shown  in  Fig.  19,  or  in   a  pan 


PREPARATIONS  FOR   AN   OPERATION.  5  I 

or  a  wash-boiler.  A  sterilizer  with  a  tray  is  better  than 
an  ordinary  pan  or  kettle,  because,  when  the  latter  is 
used,  the  metal  instruments  lie  in  the  bottom  of  the  vessel, 
where  the  heat  is  very  great  and  the  temper  may  be 
impaired.  Boiling  unfortunately  destroys  to  some  extent 
the  keenness  of  cutting  instruments,  the  ebullition  throw- 
ing them  about.  Hence  the  knives  should  be  wrapped  in 
cotton  to  preserve  the  edges.  After  sterilization  the  instru- 
ments are  placed  in  trays  containing  boiled  water.  After 
the  completion  of  the  operation  the  instruments  should  be 
scrubbed  with  soap  and  water,  boiled  in  soda  solution,  and 
dried.     Instruments  can  be  partially  disinfected  by  keeping 


them  for  fifteen  minutes  in  a  5  per  cent,  solution  of  carbolic 
acid.  Instruments  with  handles  of  wood  must  not  be  boiled. 
If  such  instruments  are  used,  they  can  be  disinfected  by  the 
use  of  carbolic  acid,  but  they  should  not  be  used.  Metal 
instruments,  whenever  possible,  should  consist  of  one  smooth 
piece.  Grooves  and  letters  are  objectionable  as  dirt  gathers 
in  such  depressions.     Ivory  handles  cannot  be  boiled. 

Whenever  possible,  give  the  patient  some  days'  rest  in 
bed  before  a  severe  operation,  and  place  him  on  a  diet  nutri- 
tious but  not  bulky.  The  night  before  the  operation  give  a 
saline  cathartic,  and  the  morning  of  the  operation  employ 
an  enema.  Emptying  the  bowels  lessens  the  danger  of 
sepsis  after  operation.  It  is  desirable  that  the  rectum  be 
empty,  because  in  shock  the  absorbing  power  of  the  stomach 
is  greatly  diminished  or  is  even  abolished  for  the  time,  and 
we  may  wish  to  utilize  the  absorbing  power  of  the  rectum 
and  give  stimulants  by  enema.  When  a  patient  is  under 
ether,  or  when  he  is  profoundly  shocked,  of  course  no 
attempt  is  made  to  give  stimulants  by  the  mouth.  Whenever 
possible,  give  a  general  warm  bath  the  day  before  the 
operation.  The  evening  before  the  operation  scrub  the 
entire  field  of  operation,  and  well  clear  of  it,  with  soap  and 
water ;  shave    if  necessary ;  wash  with  .  ether ;    scrub    well 


52  ASEPSIS  AND  ANTISEPSIS. 

with  hot  corrosive-sublimate  solution  (i  :  looo);  apply  a 
layer  of  moist  corrosive-sublimate  gauze,  and  place  over 
this  dry  antiseptic  gauze,  a  rubber  dam,  and  a  bandage. 
Many  surgeons  apply  a  poultice  of  green  soap  for  many 
hours  in  order  to  separate  masses  of  epithelium  and  with 
them  many  germs.  On  removing  the  dressings  to  per- 
form the  operation  cleanse  the  part  exactly  as  before.  In 
emergency  cases  disinfection  can  only  be  practised  just  pre- 
vious to  the  operation.  Disinfection  can  be  thoroughly 
effected  by  the  use  of  chlorinated  lime  (Weir,  Stimson). 
Surround  the  field  of  operation  with  dry  sterile  sheets. 

To  clean  the  vagina  or  rectum,  use  a  sponge  soaked 
with  creolin  and  Johnston's  ethereal  soap  (i  :  i6),  and  subse- 
quently irrigate  with  hot  saline  fluid  or  boric  acid  solution. 

If  an  operation  is  to  be  performed  within  the  mouth,  old 
snags  and  carious  teeth  should  be  removed.  To  cleanse  the 
mouth  scrub  the  teeth  with  a  brush  and  castile  soap  twice  a 
day  and  rinse  the  mouth,  nares,  and  pharynx  with  peroxid 
of  hydrogen,  or  a  solution  of  boracic  acid,  every  three  hours 
for  several  days. 

Irrigation  is  often  practised  in  septic  wounds,  but  is  not 
required  in  aseptic  wounds.  Among  irrigating  fluids  we  may 
mention  corrosive  sublimate,  carbolic  acid,  peroxid  of  hydro- 
gen, boric  acid  solution,  and  normal  salt  solution.  Hot 
normal  salt  solution  is  the  best  agent  with  which  to  irrigate 
the  peritoneal  cavity,  the  pleural  sac,  the  interior  of  joints, 
and  the  surface  of  the  brain.  This  solution  contains  0.6  per 
cent,  of  sodium  chlorid. 

Many  surgeons  employ  Landerer's  dry  method  in  oper- 
ating aseptically.  No  fluid  is  applied  to  the  wound.  As 
the  wound  is  enlarged  gauze  sponges  are  packed  in  to  arrest 
hemorrhage.  On  the  completion  of  the  operation  the  sponges 
are  removed,  any  bleeding  points  are  ligated,  and  the  wound 
is  closed  without  drainage. 

The  favorite  ligature-material  is  catgut.  Catgut  under- 
goes absorption  in  the  tissues.  Years  ago  attempts  were 
made  by  Scarpa,  Crampton,  and  Physick  to  use  absorbable 
sutures.  Sir  Astley  Cooper  tried  catgut.  These  attempts 
failed  because  the  material  employed  was  septic,  suppura- 
tion ensued,  the  wound  gaped,  and  the  ligature  was  cast 
off  prematurely.  Surgeons  remained  content  with  non- 
absorbable ligatures  of  silk  or  linen.  These  ligatures  were 
not  cut  short,  but  a  long  end  was  left  to  each  one,  and  the 
ends  were  allowed  to  hang  out  of  the  wound.  These  liga- 
tures were  lightly  pulled  upon  from  time  to  time,  and  when 


PREPARATIONS  FOR  AN  OPERATION.  53 

they  loosened  or  cut  through  were  removed.  Catgut  is  the 
submucous  coat  of  the  intestine  of  the  sheep,  and  is  the  mate- 
rial from  which  violin-strings  are  made.  It  was  reintro- 
duced into  surgery  by  Lister.  It  is  obtained  in  the  following 
manner :  The  small  intestine,  after  separation  from  the  mesen- 
tery, is  washed  in  water,  laid  upon  a  board,  and  scraped  with 
a  metal  instrument.  Thus  the  mucous  coat  and  the  mus- 
cular coat  are  scraped  away,  and  the  submucous  coat  only 
remains.  The  submucous  coat  is  cut  into  strips,  and  each 
strip  is  twisted  into  a  coil.  Raw  catgut  is  an  infected  ma- 
terial. It  is  hard  to  sterilize  because  in  the  twisting  many 
organisms  get  into  the  interior  of  the  strand,  where  it  is  diffi- 
cult for  antiseptics  to  reach  them.  Raw  catgut  obtained 
from  animals  dead  of  splenic  fever  contains  spores  of  anthrax. 
If  not  thoroughly  disinfected,  catgut  is  dangerous,  and  some 
surgeons  consider  its  cleanliness  ahvays  a  matter  of  grave 
question  and  will  not  use  it.  Surgeons'  catgut  can  be  bought 
from  the  dealer  in  skeins  containing  thirty  yards.  It  should  be 
rough  and  yellow.  The  smooth  white  variety  should  not  be 
gotten.  It  has  been  rubbed  smooth  with  a  piece  of  glass 
and  bleached  with  a  chemical,  and  in  consequence  is  weak 
and  unreliable.  The  smallest  size  is  known  as  double  zero, 
then  come  single  zero.  No.  i.  No.  2,  No.  3,  and  No.  4.  The 
usual  ligature  size  is  No.  2.  Nos.  3  and  4  are  only  used  for 
tying  thick  pedicles.  Nos.  i  and  2  are  used  for  suturing  the 
dura  and  peritoneum,  and  for  tying  small  vessels  in  the 
brain.  McBurney  and  Collins  state  that  when  catgut  is 
used  to  tie  delicate  tissue  (omental  masses,  intestinal  sur- 
faces, etc.),  it  must  first  be  softened  by  immersing  for  half  a 
minute  in  normal  salt  solution.  If  this  precaution  is 
neglected  and  wiry  catgut  is  used,  the  ligature  or  suture  will 
cut  and  hemorrhage  will  occur.^ 

If  catgut  is  thoroughly  prepared,  and  the  wound  in  Avhich 
it  is  used  is  aseptic,  it  is  a  most  satisfactory  ligature  material, 
is  absorbed  in  the  wound  after  being  cut  off  short,  and  pro- 
duces no  trouble  although  it  does  increase  slightly  wound 
secretion.  The  smaller  sizes  are  absorbed  in  four  or  five 
days,  No.  2  lasts  from  nine  to  ten  days,  Nos.  3  and  4  from 
ten  days  to  three  weeks. 

One  of  the  following  methods  of  preparation  may  be  used  : 
The  catgut  is  soaked  in  ether  for  twenty-four  hours  to 
remove  fat.  It  is  then  wound  on  glass  spools,  trans- 
ferred to  alcohol,  and  boiled  under  pressure.  The  boil- 
ing is  conducted  in    a   heavy  metal  jar  with    a    well-fitting 

^  Inta-naiional  Text-Book  of  Stirgeiy. 


54  ASEPSIS  AND  AjVT/SEPSIS. 

screw-top.  The  jar  is  half  filled  with  alcohol.  The  spools 
of  catgut  are  placed  in  the  jar,  the  lid  is  screwed  down, 
and  the  apparatus  is  immersed  in  boiling  water  for  half  an 
hour.  The  gut  is  kept  in  this  jar  until  needed.  Fowler's 
catgut  is  prepared  by  boiling  in  alcohol.  It  is  placed  in 
hermetically  sealed  V-shaped  glass  tubes.  Each  tube  con- 
tains alcohol  and  twelve  ligatures.  The  alcohol  is  boiled  by 
innncrsijig  tlic  tube  in  boiling  water.  The  cumol  method  is 
employed  by  Kelly  in  the  Johns  Hopkins  Hospital,  and 
is  known  as  Kronig's  method.  Cumol  is  a  fluid  hydrocarbon 
which  boils  at  179°  C.  Catgut  is  wound  upon  spools  of 
glass,  and  these  are  placed  in  a  beaker-glass,  the  bottom 
of  which  is  covered  with  cotton.  A  bit  of  cardboard  is 
placed  on  top  of  the  beaker,  and  through  a  small  perfora- 
tion in  the  cardboard  a  thermometer  is  introduced.  The 
beaker  is  placed  in  a  sand-bath  and  the  bath  is  heated  by 
means  of  a  Bunsen  burner.  The  temperature  is  gradually 
raised  to  80°  C,  and  is  kept  at  this  point  for  one  hour, 
in  order  entirely  to  remove  moisture  from  the  gut.  Cumol, 
at  a  temperature  of  100°  C,  is  poured  into  the  glass,  and 
the  heat  is  increased  until  the  temperature  of  the  cumol 
is  about  5  degrees  below  its  boiling-point  (165°  C).  For 
one  hour  this  temperature  is  maintained.  Then  the  cumol 
is  poured  off  and  the  catgut  is  allowed  to  remain  for  a  time 
in  the  sand-bath  at  a  temperature  of  100°  C,  in  order  to 
dry.  It  is  transferred  for  keeping  into  sterile  glass  jars  or 
test-tubes.^ 

The  formalin  method  is  advocated  by  the  elder  Senn. 
The  catgut  is  wound  on  glass  test-tubes,  and  is  immersed  in 
an  aqueous  solution  of  formalin  (2-4  per  cent.)  for  twenty- 
four  to  forty-eight  hours.  It  is  placed  in  running  water  for 
twelve  hours  to  get  rid  of  the  formalin.  It  is  boiled  in 
water  for  fifteen  minutes,  is  cut  in  pieces  and  tied  in  bundles, 
placed  in  a  glass-stoppered  jar,  and  is  kept  ready  for  use  in 
the  following  mixture:  950  parts  of  absolute  alcohol,  50 
parts  of  glycerin,  and  100  parts  of  pulverized  iodoform. 
Every  few  days  the  mixture  should  be  shaken. 

Senn's  process  is  a  modification  of  Hoffmeister's.  Even 
sterile  catgut  contains  a  toxic  substance  which  increases 
wound  secretion,  has  a  poisonous  effect  on  body  cells,  and 
favors  to  some  extent  limited  suppuration.  Senn  maintains 
that  in  order  to  counteract  this  influence  gut  should  not 
only  be  sterile,  but  should  be  antiseptic  to  inhibit  the  growth 

^  See  McBurney  and  Collins,  in  hiternational  Text-Book  of  Surgery,  and 
Clark,  m  Johns  Hopkins  Hospital  Bulletin,  March,  1896. 


PREPARATIONS  FOR  AN  OPERATION.  55 

of  pyogenic  organisms  which  reach  the  wound  during  opera- 
tion or  by  the  blood. 

Bceckman  wraps  catgut  in  paraffin-paper,  seals  it  in  a 
paper  envelope,  puts  it  in  the  sterilizer,  and  subjects  it  to  dry 
heat.  For  three  hours  it  is  heated  to  a  temperature  of  284° 
F.,  and  for  four  hours  to  a  temperature  of  290°  F.  The  envelope 
can  be  carried  in  the  pocket  or  the  instrument-bag.  When 
the  gut  is  wanted  the  end  of  the  envelope  is  torn  off,  an 
assistant  with  sterilized  hands  unwraps  the  paraffin-paper, 
and  the  gut  is  dipped  for  a  moment  in  sterile  water  to  make 
it  pliable.^ 

A  method  which  has  been  largely  used  is  to  take  raw  cat- 
gut, keep  it  in  ether  for  twenty-four  hours,  soak  it  for  twenty- 
four  hours  in  an  alcoholic  solution  of  corrosive  sublimate 
(i  :  500),  wind  it  on  sterilized  glass  rods,  and  place  it  for 
keeping  in  ether  or  in  alcohol.  Johnston's  quick  method 
of  preparing  catgut  is  as  follows  :  place  it  for  twenty-four 
hours  in  ether ;  at  the  end  of  this  period  place  it  in  a  solu- 
tion containing  20  grains  of  corrosive  sublimate,  100  grains 
of  tartaric  acid,  and  6  ounces  of  alcohol.  The  small  gut  is 
kept  in  this  for  ten  or  fifteen  minutes,  the  larger  gut  from 
twenty  to  thirty  minutes,  but  never  longer.  It  is  placed  for 
keeping  in  a  mixture  containing  i  drop  of  chlorid  of  palla- 
dium to  8  ounces  of  alcohol.  This  gut  is  strong  and  reli- 
able. At  the  time  of  operation  the  gut  is  placed  in  a  solution 
one-third  of  which  is  5  per  cent,  carbolic-acid  solution  and 
two-thirds  of  which  are  alcohol.  Chromicized  catgut  is 
absorbed  less  rapidly  than  ordinary  catgut.  It  is  used  to 
tie  thick  pedicles  and  large  arteries,  to  suture  nerves  and 
tendons,  and  as  a  suture-material  in  the  radical  cure  of 
hernia.  Chromicized  gut.  No.  3  and  No.  4,  will  remain  un- 
absorbed  in  the  tissues  from  four  to  six  weeks.  The  gut  should 
be  soaked  in  ether  for  twenty-four  hours,  and  placed  for 
twenty-four  hours  in  a  4  per  cent,  solution  of  chromic  acid 
in  water.  The  gut  is  then  dried  in  a  hot-air  sterilizer 
and  disinfected  by  one  of  several  methods.  The  cumol 
method  is  satisfactory. 

Kangaroo-tendon  will  be  absorbed  in  the  tissues,  but  only 
after  a  longtime  (sixty  to  seventy  days).  This  material  is  es- 
pecially useful  as  a  buried  suture  in  hernia-operations.  It  can 
be  prepared  in  the  same  manner  as  the  chromicized  catgut,  and 
it  ought  always  to  be  chromicized.  Marcy's  plan  is  as  fol- 
lows :  Soak  the  dried  tendon  in  a  solution  of  corrosive  subli- 
mate (i  :  1000)   and   separate  the  individual  strands.     Dry 

*  James  E.  Moore,  in  Philada.  Med.  Journal,  June  22,  1898. 


56  ASEPSIS  AND  ANTISEPSIS. 

each  strand  in  an  antiseptic  towel.  Chromicize  the  gut  and 
keep  until  needed  in  boiled  linseed  oil  containing  5  per  cent, 
of  carbolic  acid.  Before  using  the  strands  take  them  out  of 
the  oil,  wipe  off  the  oil  with  a  sterile  towel,  and  immerse  the 
tendon  for  half  an  hour  in  a  i  :  looo  solution  of  bichlorid  of 
mercury.  Silk  can  be  used  for  both  ligatures  and  sutures ; 
many  sizes  should  be  kept  on  hand.  White  silk  may  be 
used,  or  black  silk,  which  is  more  easily  visible.  Silk  is  not 
absorbed  but  is  encapsuled.  It  is  not  a  good  material  for 
buried  sutures,  as  in  the  long  run  it  may  form  a  sinus.  Sutures 
of  silk  should  be  boiled  for  half  an  hour  before  using  in  a 
I  per  cent,  solution  of  carbonate  of  sodium.  A  convenient 
method  of  preparation  is  to  wind  the  silk  on  a  glass  spool, 
place  the  spool  in  a  large  test-tube,  close  the  mouth  of  the 
tube  with  jewellers'  cotton,  introduce  the  tube  into  a  steam 
sterilizer,  and  subject  it  to  a  pressure  of  ten  pounds  for  twenty 
minutes,  repeating  the  process  the  next  day.  These  tubes 
are  carried  in  wooden  boxes  sealed  with  rubber  corks.  Silk- 
zvonn-gut  contains  fewer  bacteria  than  catgut  and  does  not 
swell  when  introduced  into  a  wound.  It  is  a  very  valuable 
suture-material,  but  is  not  used  for  ligatures.  Silkworm-gut 
is  prepared  by  placing  it  in  ether  for  forty-eight  hours  and  in 
a  solution  of  corrosive  sublimate  (i  :  1000)  for  one  hour,  or 
it  can  be  boiled  in  plain  water  for  half  an  hour.  It  is  carried 
in  a  long  tube  filled  with  alcohol.  A  few  minutes  before 
using  the  gut  is  placed  in  carbolic  acid  and  alcohol  (one- 
third  of  the  solution  is  a  5  per  cent,  solution  of  acid,  two- 
thirds  of  it  are  alcohol).  Silk  and  catgut  should  be  tied  by 
the  reef-knot.  Silkworm-gut  is  tied  by  the  surgeon's  knot. 
In  tying  catgut  the  first  knot  is  tied  tightly,  and  the  second 
knot  firmly  but  not  tightly.  If  the  second  knot  is  tied 
tightly,  it  is  apt  to  cut  the  ligature  (Greig  Smith).  Silver 
wii'e  is  prepared  by  boiling.  It  is  a  very  useful  suture- 
material,  as  it  can  be  thoroughly  sterilized  and  has  an 
inhibitory  effect  on  the  growth  of  bacteria.  Some  sur- 
geons use  it  for  buried  sutures,  but  many  are  opposed  to 
using  it  thus  on  the  ground  that  it  is  apt  to  lead  to  sinus- 
formation. 

Most  wounds  are  closed  by  interrupted  sutures  of  silk- 
worm-gut, but  silk,  catgut,  chromic  catgut,  or  silver  wire  can 
be  used.  The  old  continuous  suture  (glovers'  stitch)  is  rarely 
used.  An  admirable  closure  can  be  effected  by  Halsted's 
subcuticular  stitch,  and  scarcely  any  scar  results.  Marcy's 
buried  tendon  sutures  are  very  valuable,  especially  in  hernia- 
operations  and  in  various  operations  upon  the  abdomen. 


PKEPAKATIONS  FOR   AiY  OPERATION. 


57 


Dressings  are  made  of  cheese-cloth.  In  order  to  make 
antiseptic  gauze  the  cheese-cloth  is  boiled  in  a  solution  of 
carbonate  of  sodium,  rinsed  out,  and  dried ;  it  is  then  soaked 
for  twenty-four  hours  in  a  solution  containing  i  part  of  cor- 
rosive sublimate,  2  parts  of  table-salt,  and  500  parts  of  water. 
It  is  placed  in  clean  jars  with  glass  lids,  and  it  may  be 
kept  moist  or  dry. 

Sterilized  or  aseptic  gauze  is  prepared  by  boiling  in  car- 
bonate of  sodium,  etc.,  as  described  under  Antiseptic  Gauze. 
It  is  wrapped  in  a  towel  and  is  placed  in  a  steam-sterilizer 
for  an  hour  (Fig.  20).  It  is  kept  in  sterile  glass  jars  with 
glass  lids.  The  pads  for  sponging  are  made  by  rolling  up 
portions   of  sterile   gauze.      Ashton's  abdominal    pads    are 


Fig.  20. — LautenschKiger's  steam-sterilizer   for   dressings  :    A,  exterior   view  ;  B, 
cross-section. 


made  by  taking  several  layers  of  sterile  gauze,  each  piece 
about  six  inches  long  and  four  inches  wide,  running  a  stitch 
around  the  margin,  and  sewing  a  piece  of  tape  into  one 
corner. 

Sterile  absorbent  cotton  is  prepared  in  the -same  manner 
as  gauze.  Cotton  is  useful  as  a  dressing  to  supplement 
gauze,  being  placed  on  the  outside  of  the  gauze.  It  absorbs 
quantities  of  serum,  but  will  take  up  very  little  pus. 

Iodoform  gauze  is  very  useful  for  packing  in  the  brain  and 
abdomen,  for  packing  abscesses  and  tubercular  areas,  and 
for  dressing  foul  wounds.  It  is  prepared  as  follows  :  Make 
an  emulsion  composed  of  equal  parts  by  weight  of  iodoform, 


58  ASEPSIS  A  AD  AA'TISEPSIS. 

glycerin,  and  alcohol,  and  add  corrosive  sublimate  in  the 
proportion  of  i  part  to  the  looo  of  the  mixture.  This  mixt- 
ure stands  for  three  days.  Take  moist  bichlorid  gauze, 
saturate  it  with  the  emulsion,  let  it  drip  for  a  time,  and  keep 
it  in  sterilized  and  covered  glass  jars  (Johnston).  Lister's 
cyanid  gauze  (double  cyanid  of  zinc  and  mercury)  is  not  cer- 
tainly antiseptic,  and  must  be  dipped  into  a  corrosive-subli- 
mate solution  (i  :  2000)  before  using.  All  forms  of  gauze 
can  be  bought  ready  prepared  from  reliable  firms.  Some 
surgeons  place  silver  foil  upon  a  wound  before  applying  the 
gauze  (Halsted,  p.  30J.  Small  v\-ounds  in  which  drainage  is 
not  employed  may  often  be  dressed  by  laying  a  film  of 
aseptic  absorbent  cotton  over  the  wound  and  applying,  by 
means  of  a  clean  camel's-hair  brush,  iodoform  collodion  (grs. 
xlviij  of  iodoform  to  5]  of  collodion j. 

When   a  wound  is   dressed  with   gauze  a  rubber-dam  is 
sometimes  laid  over  the  dressings,  so  as  to  diffuse  the  dis- 


FiG.  21. — Drainage-tubes:  ^-J,  glass;  ^,  rubber. 

charge  and  prevent  it  from  coming  rapidl}-  to  the  surface. 
The  use  of  the  rubber-dam  is  not  nearly  so  common  as  for- 
merly. In  an  aseptic  wound  dry  dressing  uncovered  by  rub- 
ber is  the  most  useful.  When  a  dressing  is  covered  by  an 
impermeable  material  it  becomes  wet,  acts  as  a  poultice,  and 
the  discharges  on  the  dressing  may  undergo  decomposition. 
A  rubber-dam  before  being  used  should  be  Avashed  with 
soap  and  water  and  soaked  in  a  solution  of  corrosive  sublimate. 
Drainage  is  obtained  when  needed  b}-  rubber  or  glass  tubes, 
by  strands  of  horsehair,  silkworm-gut,  or  catgut,  or  by  pieces 
of  gauze.  Rubber  drainage-tubes  (Fig.  2\,  B)  are  prepared 
by  boiling  in  plain  water.  They  are  kept  until  wanted  in  a 
mercurial  solution.  This  solution  should  be  changed  eveiy 
few  days,  because  the  mercury  is  apt  to  be  precipitated  as 
sulphid.  Glass  tubes  are  prepared  by  boiling.  A  bit  of 
rubber  tissue  is  sometimes  used  for  drainage.  This  material 
is  also   used  to  cover  surfaces  which  have  been  skin-grafted. 


SEAWS  DECALCIFIED   BOAE-CHIPS.  59 

Rubber  tissue,  before  being  placed  on  or  in  a  wound,  must 
be  washed  with  soap  and  water,  rinsed  in  sterile  water,  and 
soaked  in  a  solution  of  corrosive  sublimate.  Gauze,  catg-ut, 
etc.,  are  known  as  capillary  drains.  When  moist  they  drain 
serum  excellenth',  but  pus  very  badly  or  not  at  all.  Drainage- 
tubes  or  strands  are  brought  out  at  a  portion  of  the  wound 
which  will  be  dependent  when  the  patient  is  recumbent. 
Drainage  is  used  in  all  infected  wounds,  in  most  very  large 
wounds,  in  wounds  to  which  irritant  antiseptics  have  been 
applied,  and  in  cases  in  which  large  abnormal  cavities  exist. 
Dressings  must  be  changed  as  soon  as  soaking  is  apparent, 
or  if  constitutional  symptoms  of  wound  infection  arise, 
and  the  change  must  be  effected  with  all  of  the  aseptic  care 
employed  in  the  operation.  Stitches  may  usually  come  out 
from  the  sixth  to  the  eighth  day,  although  if  there  is  much 
tension  on  the  edges  of  the  wound  they  are  allowed  to 
remain  several  days  longer.  In  large  wounds,  half  of  the 
stitches  are  taken  out  at  one  time,  the  remainder  being 
allowed  to  remain  for  a  couple  of  days  longer.  When  a 
stitch  begins  to  cut  it  is  doing  no  good,  and  it  should  be 
removed  no  matter  how  short  a  time  it  has  been  in  place. 
If  it  is  allowed  to  remain,  it  will  cut  into  the  wound,  make  a 
stitch-abscess,  and  cause  an  irregular  suture-line. 

Preparation  of  Marine  Sponges. — [Marine  sponges  are 
rarely  used.  Gauze  pads  are  preferred.  Marine  sponges 
absorb  admirably,  but  they  are  hard  to  clean  when  new  and 
cannot  be  certainly  sterilized  in  their  interiors  after  becom- 
ing badly  infected.  They  may  be  prepared  as  follows : 
Beat  out  the  dust ;  place  them  for  fort\--eight  hours  in  a 
solution  of  hydrochloric  acid  (15  per  cent);  wash  them 
with  water;  place  them  for  one  hour  in  a  solution  of  per- 
manganate of  potassium  (giij  to  5  pints  of  water) ;  soak  for 
four  hours  in  a  solution  containing  10  ounces  of  hyposul- 
phite of  sodium,  5  ounces  of  hydrochloric  acid,  and  3  pints 
of  water ;  wash  with  running  water  for  six  hours.  Keep  the 
sponges  in  a  jar  containing  corrosive-sublimate  solution 
(i  :  1000).  After  using,  wash  in  hot  water,  soak  for  half  an 
hour  in  a  solution  of  sodium  carbonate  (i  :  32),  wash  in  hot 
water,  and  replace  in  corrosive  sublimate. 

Senn's  Decalcified  Bone-chips. — Take  the  shaft  of  the 
tibia  or  femur  of  a  recently  killed  ox,  saw  it  into  portions 
two  inches  in  length,  remove  the  marrow  and  periosteum, 
and  place  the  fragments  of  bone  in  a  15  percent,  solution 
of  hydrochloric  acid.  Change  the  solution  ever\'  twenty- 
four  hours.     In   from   two  to   four  weeks  the  bone  will  be 


6o  INFLAMMA  TTOA\ 

decalcified.  Wash  in  distilled  water,  place  the  pieces  of  de- 
calcified bone  for  a  few  minutes  in  a  dilute  solution  of  potash 
to  neutralize  the  acid,  and  then  immerse  for  twenty-four 
hours  in  distilled  water.  The  portions  of  bone  are  cut  into 
strips  in  the  direction  of  the  long  axis  of  the  segments. 
Each  strip  is  three-quarters  of  an  inch  wide  and  should  be 
sliced  into  bits  one  millimeter  thick.  These  chips  are  kept 
in  an  alcoholic  solution  of  corrosive  sublimate  (i  :  500). 

III.  INFLAMMATION. 

Definition. — When  the  tissues  are  injured  they  react  or 
respond,  and  this  reaction  or  response  is  known  as  inflamma- 
tion. The  process  of  inflammation  is  defined  by  Professor 
Burdon-Sanderson  as  "  the  succession  of  changes  which 
occur  in  a  living  tissue  when  it  is  injured,  provided  that  the 
injury  is  not  of  such  a  degree  as  at  once  to  destroy  its 
structure  and  vitality."  Professor  Adami,  in  his  article  upon 
inflammation  in  Allbutt's  System  of  Medicine,  points  out  that 
this  definition  really  includes  too  much.  He  alludes  to  the 
hemorrhage  which  occurs  in  the  liver  after  a  traumatism, 
and  the  subsequent  changes  in  the  extrav^asated  corpuscles, 
and  points  out  that  these  changes  are  not  inflammatoiy  phe- 
nomena. This  definition,  however,  includes  all  inflammatory 
conditions,  is  largely  employed,  is  ver\^  useful,  indicates  the 
cause,  and,  as  Burdon-Sanderson  says,  makes  clear  that 
inflammation  is  a  process  and  not  a  state  (Adami.)  Adami's 
definition  is  as  follows  :  "  The  series  of  changes  constituting 
the  local  manifestation  of  the  attempt  at  repair  of  actual  or 
referred  injury  to  a  part,  or,  briefly,  the  local  attempt  at 
repair  of  actual  or  referred  injury."  The  changes  alluded  to 
in  Burdon-Sanderson's  definition  comprise — (i)  changes  in 
the  vessels  and  the  circulation ;  (2)  departure  of  fluids  and 
solids  from  the  vessels ;  and  (3)  changes  in  the  perivascular 
tissues. 

Vascular  and  circulatory  changes  were  formeily 
thought  to  be  absolutely  essential  to  inflammation  in  both 
vascular  and  non-vascular  tissues.  In  the  former  they  occur 
in  the  inflamed  tissues  ;  in  the  latter  (cornea  and  cartilage) 
they  are  manifest  in  neighboring  tissues  from  which  the  non- 
vascular area  derives  its  nutritive  material.  As  a  matter  of 
fact,  in  inflammation,  vascular  changes  are  almost  always 
present ;  but  in  a  rather  trivial  corneal  inflammation  the 
episcleral  vessels  may  not  dilate,  and  the  only  white  corpuscles 
which  gather  in  the  damaged  area  are  those   which   come 


ACTIVE    HYPEREMIA. 


6i 


from  the  lymph-spaces  of  the  cornea.  Inflammation  in  any 
tissue  will  not  be  accompanied  by  vascular  dilatation  unless 
the  process  reaches  a  certain  stage  of  severity. 

Active  Hyperemia. — When  an  irritant  is  applied  to 
tissue  there  ma}-  be  a  momentary  arterial  contraction  due 
to  irritation  of  the  nerves,  but  this  contraction  is  transitory, 
and  is  not  an  inflammatory  phenomenon.  The  first  vascu- 
lar phenomenon  is  dilatation  of  all  the  vessels — capillaries, 
venules,  and  arterioles — appearing  first  and  being  most  pro- 
nounced in  the  small  arteries.  As  a  result  of  the  dilatation 
there  are  increased  rapidity  of  circulation  and  increased  deter- 
mination of  blood  to  the  part,  and  the  area  of  hyperemia 
becomes  warmer  than  is  normal.  This  condition  of  in- 
creased circulator}-  activit}-  is  known  as  "  active  hyperemia  " 
(Fig.  23). 

Active  hyperemia  is  an  increase  in  the  amount  of  moving 
blood  in  a  part.  Passix'e  hyperemia  is  an  increase  in  the 
amount  of  blood  in  a  part, 
but  not  of  moving  blood, 
as  passive  hyperemia  or 
congestion  is  due  to  venous 
obstruction,  and  the  blood 
is  stagnated.  Plethora 
means  an  increase  in  the 
total  amount  of  body 
blood.  Diminution  in  the 
amount  of  blood  in  a  part 
is  ischemia.  Anemia  is  a 
diminution  in  the  amount 
of  blood  in  the  whole  body 
because  of  hemorrhage  or 
because  of  insufficient  for- 
mation of  blood.  Local 
anemia  is  the  complete 
cutting  of  the  blood-supply 
of  a  part. 

In  active  h}-peremia 
more  blood  goes  to  the 
part  and  more  blood  passes  through  it,  an  increased  amount 
of  venous  blood  comes  from  the  hyperemic  area,  the  venous 
tension  is  increased,  and  the  veins  ma}^  even  pulsate.  The 
capillaries,  which  under  ordinary  circumstances  contain  but 
few  blood-cells  (Fig.  22),  become  filled  with  corpuscles 
(Fig.  23),  and  even  the  smallest  capillaries  pulsate.  The 
blood  in  the  veins  adjacent  to  the  area  of  inflammation  is  of 


Fig.  22. — Normal  vessels  and  blood-stream. 


62  INFLAMMATION. 

a  much  lighter  red  than  in  health.  Many  capillaries  which 
were  invisible  under  normal  conditions  become  \isible  when 
active  hyperemia  exists.  The  capillaries  contain  no  muscle- 
fiber,  and  hence  these  tubes  cannot  actively  contract,  except 
so  far  as  the  caliber  of  the  tubes  is  altered  by  the  contraction 
or  expansion  of  the  endothelial  cells  of  the  capillary  wall. 
Contraction  and  dilatation  of  the  capillaries  depend  chiefly 
upon  the  amount  of  blood  sent  to  or  retained  in  them.  In 
active  hyperemia  the  increased  amount  of  blood  sent  to  the 
part  causes  capillary  dilatation.  As  a  result  of  the  dilatation 
the  endothelial  cells  become  thinner  than  before,  the  cells  as 
a  result  of  irritation  lose  some  of  their  power  to  restrain 
exudation,  and  some  observers  assert  that  openings  are 
formed  between  the  cells  or  that  previously  existing  open- 
ings enlarge.  Fluid  elements  rarely  leave  the  blood-vessels 
during  active  hyperemia,  but  they  occasionally  do.  The 
wheals  of  urticaria  are  thus  formed  (Warren).  Active 
hyperemia  is  often  the  first  stage  of  an  inflammation,  but 
it  is  not  of  necessity  followed  by  other  inflammatory 
changes,  and  it  can  be  caused  by  nerve-section  or  nerve- 
stimulation. 

The  duration  of  active  hyperemia  is  variable.  If  the  irri- 
tation was  brief,  the  hyperemia  is  very  transitory.  If  the 
irritation  is  prolonged,  it  may  last  some  time  before  giving  way 
to  retardation.  In  the  web  of  a  frog's  foot,  if  an  irritant  is 
applied,  hyperemia  lasts  from  one-half  hour  to  two  hours 
before  it  is  replaced  by  retardation. 

A  hyperemic  part,  if  in  or  near  the  surface,  is  red  in  color, 
imparts  a  sense  of  heat  to  the  examining  hand,  the  color 
quickly  disappears  on  pressure  and  quickly  returns  when 
pressure  is  released.  In  a  congested  part  the  temperature 
is  diminished,  the  surface  is  purple,  the  color  slowly  dis- 
appears on  pressure  and  slowly  returns  when  pressure  is 
removed ;  there  are  edema  and  a  sensation  of  coldness  and 
numbness. 

Retardation. — After  active  hyperemia  has  existed  for  a 
variable  time  the  blood-current  begins  to  lessen  in  velocity, 
until  it  becomes  more  tardy  than  in  health.  This  is  known 
as  "  retardation  of  the  circulation."  Retardation  is  first  noted 
in  the  venules,  next  in  the  capillaries,  and  last  in  the  arteri- 
oles ;  but  arterial  pulsation  continues.  The  red  cells  take 
the  center  of  the  blood-stream,  which  is  known  as  the  axial 
current.  The  white  corpuscles  drop  out  of  the  central 
stream,  separate  from  the  red,  and  float  lazily  along  near  the 
vessel-wall.     The    white   cells   show   a  strong  tendency  to 


OSCILLATION  AND   STAGNATION. 


63 


Fig.  23. — Dilatation  of  the  vessels    in  inflammation. 


adhere  to  the  venule-walls,  and,  as  a  result,  accumulate  against 
the  inside  of,  and  stick 
to,  these  walls  and  to 
one  another,  until  the 
veins  are  entirely  lined 
with  la\-ers  oi  leukocytes 
(Fig.  23).  In  the  capil- 
laries some  leukocytes 
gather,  but  not  many. 
In  the  arteries  the}'  ad- 
here during  cardiac  dila- 
tation, but  are  swept 
away  b}'  the  force  of  the 
heart's  contractions. 
Retardation  is  believed 
to  be  chiefly  due  to 
paresis  of  the  muscular 
walls  of  the  arterioles. 
This  causation  seems 
probable  when  we  recall 
Lord  Lister's  experi- 
ments upon  the  pig- 
ment-cells of  the  frog's 

foot.  Lister  proved  that  inflammation  paralyzes  the  pigment- 
cells,  and  concluded  that  dilatation  at  the  focus  of  an  inflam- 
mation is  due  to  the  paralyzing  action  of  an  irritant.  Dila- 
tation at  a  distance  from  the  focus  is  a  reflex  phenomenon 
(W.  \\'atson  Che}-ne).  When  the  vessels  are  weakened  or 
paralyzed  the  contractions  of  the  arterioles  are  feeble  or 
absent,  and  the  blood  is  no  longer  urged  forward  by  arterial 
power.  The  endothelial  cells  of  the  vessels  enlarge  and 
develop  a  condition  of  stickiness,  which  leads  the  white  cells 
to  adhere  to  them,  and  thus  increases  resistance  to  the 
current  of  blood  and  adds  to  retardation.  Fluids  pass 
through  a  vessel  in  this  condition  more  readih'  than  a 
healthy  vessel,  and  white  corpuscles  lea\-e  the  \-essel  in  large 
numbers. 

Oscillation  and  Stagnation. — By  this  accumulation  of 
leukocytes  the  blood-stream  is  progressively  narrowed  and 
the  axial  current  is  impeded.  The  red  blood-cells  begin  to 
stick  to  one  another,  forming  aggregations  like  rouleaux  of 
coin,  which  masses  increase  the  difficulty  the  axial  current 
has  to  contend  with,  until  progressive  movement  ceases  and 
the  contents  of  the  vessels  sway  to  and  fro  with  the  heart- 
beat.    This  is  the  staee  of  oscillatiou.     In  a  short  time  oscil- 


64 


INFLAMMA  TION. 


lation  ceases  and  the  vessels  are  filled  with  blood  which  does 
not  move,  and  the  vessel-walls  become  irregular  in  outline  or 
even  pouched.  This  stage  is  known  as  "  stasis  "  or  "  stag- 
nation "  (Fig.  24).  If  stasis  persists,  coagulation  occurs, 
because  the  vessel-walls  have  been  so  injured  by  the  irritant 
as  to  be  practically  dead  material,  and  they  are  no  longer 

able  to  prevent  clotting 
of  their  contents.  Stasis 
is  chiefly  due  to  paralysis 
and  damage  of  the  vessel- 
walls.  Diapedesis  ceases 
when  stasis  takes  place. 
We  can  then  sum  up  the 
vascular  changes  of  in- 
flammation by  stating  that 
they  consist  in  a  dilatation 
of  the  small  vessels  and  a 
primary  acceleration,  a 
secondary  retardation, 
and  a  subsequent  stagna- 
tion of  the  blood-current 
with  adhesion  of  leuko- 
cytes to  the  walls  of  veins 
and  capillaries,  migration 
of  leukocytes,  and  the 
aggregation  into  masses 
of  the  red  blood-cells.  If 
stasis  persists,  the  vessel- 
walls  become  profoundly 
involved  in  the  inflammatory  change,  and  they  may  rupture 
or  be  completely  destroyed. 

Exudation  of  Fluids. — It  is  to  be  remembered  that  in 
the  process  of  nutrition  serum  and  even  white  cells  pass  into 
the  tissues  through  the  walls  of  veins  and  capillaries.  When- 
ever inflammatory  retardation  of  the  circulation  arises,  there 
is  an  increase  in  the  amount  of  plasma  which  passes  out  of 
the  vessels,  but  in  inflammation  the  exudation  is  vastly 
greater  in  amount  and  is  different  in  composition.  In  a 
slight  inflammation,  and  in  the  early  stage  of  any  inflam- 
mation, there  is  an  increase  in  the  fluid  exudate,  and  we 
speak  of  the  condition  as  "  serous  inflammation."  This  fluid 
is  really  not  serum,  but  is  liquor  sanguinis.  We  find  true 
serum  in  passive  congestion,  not  in  active  inflammation. 
The  fluid  in  a  serous  exudation  contains  very  few  white 
cells,  and  hence  little  or  no  fibrin  can  form  in  it,  and  coagu- 


FiG.  24. — Stasis  of  blood  and  diapedesis  of  white 
corpuscles  in  inflammation. 


EXUDATION  OF  FLUIDS.  65 

lation  does  not  take  place  in  the  perivascular  tissues ;  and  if 
the  innaniniation  goes  no  further,  the  exudate  is  absorbed  by 
the  lymphatics.  A  blister  is  an  example  of  serous  inflam- 
mation. If  the  inflammation  continues  to  intensify,  the 
exudation  is  altered  in  character — it  becomes  thicker,  turbid, 
and  very  coagulable.  It  contains  white  cells  and  fibrin- 
elements,  and  coagulates  in  the  tissues,  because  some  of  the 
leukocytes  break  up  and  set  free  fibrin-ferment,  and  fibrin- 
ferment  causes  the  union  of  calcium  and  fibrinogen  and  the 
formation  of  fibrin.  This  fluid  is  known  as  "  lymph,"  or 
plastic  exudation,  and  when  it  is  present  we  speak  of  the 
condition  as  "  plastic  inflammation."  The  lymphatics  en- 
deavor to  absorb  the  fluid,  but  become  occluded  by  coagu- 
lation, and  the  area  they  drain  becomes  swollen,  hard,  and 
"  brawny."  Lymph  can  be  seen  in  the  anterior  chamber  of 
the  eye  in  cases  of  plastic  iritis.  The  slighter  the  inflamma- 
tion the  less  albuminous  is  the  fluid — the  more  intense  the 
inflammation  the  more  albuminous  is  the  fluid.  The  focus 
of  an  inflammation  usually  feels  brawny  because  of  coagula- 
tion of  a  highly  albuminous  exudate — the  periphery  of  an 
inflammation  is  soft  and  edematous  because  of  the  presence 
there  of  thin  and  non-coagulable  exudate.  Inflammatory 
lymph  contains  proteids  and  other  substances.  "  Of  these 
the  more  important  are  ferments,  the  results  of  proteolysis 
(notably  fibrin  and  its  precursors  and  peptones),  and  in  many 
cases  mucin,  together  with  bactericidal  substances,  and, 
where  bacteria  are  present,  the  products  of  their  growth."  '^ 
The  amount  of  the  exudation  varies  with  the  violence  of  the 
irritation,  the  nature  of  the  irritant,  the  general  condition  of 
the  organism,  and  the  state  of  the  tissues  which  are  involved. 
In  dense  tissue  (bone,  periosteum,  etc.)  the  exudation  is 
scanty.  In  loose  tissues  (subcutaneous  tissue)  it  is  profuse. 
Profuse  exudation  may  take  place  into  a  joint,  the  pleural  sac, 
the  peritoneal  cavity,  or  the  pericardium. 

Does  the  plasma  leave  the  vessels  as  a  simple  filtrate  ? 
Some  maintain  that  it  does.  Heidenhain  and  others  claim 
that  it  does  not,  and  believe  that  the  endothelial  cells  play  an 
active  part  in  the  process.  Heidenhain  likens  exudation  to 
secretion,  because  some  materials  from  the  plasma  pass  out 
and  others  do  not.  Adami  is  inclined  to  agree  with  Heiden- 
hain, that  the  epithelium  plays  "  not  a  passive,  but  an  active 
role."  It  is  a  question  if  open  spaces  do  or  do  not  exist 
between  the  endothelial  cells,  but  the  existence  of  such 
spaces  has  not  been  proved. 

^  Adami,  in  Allbutt's  System  of  Medicine. 
5 


66 


I  NFL  A  MM  A  TION. 


Diapedesis  and  Migration. — Even  early  in  an  inflam- 
mation some  few  white  corpuscles  pass  through  the  vessel- 
walls  ;  but  when  the  inflammation  is  well  established  large 
numbers,  and  when  it  is  severe  vast  hordes,  pass  into  the 


Fig.  25. — Stages  of  the  migration  of  a  single  white  hlood-corpuscle  through  the  wall  of  a  vein 

(Caton). 

perivascular  tissues.  This  process  is  known  as  "  diapedesis," 
or  "migration"  (Fig.  25).  The  leukocytes  throw  out  proto- 
plasmic arms,  insert  themselves  between  the  cells  of  the 
walls  of  the  vessel,  and  pull  themselves  through  by  their 
power  of  ameboid  movement  (Fig.  26).    Most  observers  claim 


Fig.  26. — Ameboid  movements  of  a  leukocyte  (Warren). 


that  they  do  not  pass  through  existing  open  doors,  but  form 
openings  which  close  after  them.  This  is  readily  accom- 
plished, because  the  vessel-wall  is  itself  damaged,  weakened, 
and  convoluted.     Others  claim   that  stomata  exist  between 


CHAXGES  IX   THE   PERIVASCULAR    TISSUES.  67 

the  epithelial  cells,  the  vessel-wall  being  porous  like  a  filter. 
The  escape  of  leukocytes  takes  place  chiefly  from  the 
venules,  though  some  migrate  through  the  capillaries  and 
even  the  arterioles  (Fig.  25). 

The  leukocytes  are  influenced  to  move  toward  the 
damaged  tissue  by  the  attractive  force  known  as  posi- 
tive "  chemiotaxis,"  a  force  which  draws  them  toward  in- 
vading bacteria,  to  regions  of  irritation,  and  to  areas  of 
tissue-death.  Leukocytes  may  move  from  very  virulent 
organisms,  influenced  by  what  is  known  as  negative 
chemiotaxis.  The  migration  of  a  leukocyte  requires  but 
a  short  time.  Fig.  25  shows  the  migration  of  a  white 
blood-cell  through  a  vein-wall,  the  process  requiring 
one  hour  and  fifty  minutes.  In  very  acute  inflammations, 
red  corpuscles  pass  into  the  tissues.  Red  corpuscles  are 
not  capable  of  ameboid  movements,  and  they  escape 
through  damaged  areas  in  the  capillary  walls.  The  white 
corpuscles  usually  greatly  increase  in  number  in  the  blood 
of  a  person  who  has  an  acute  inflammation  (leukocytosis), 
and  the  blood-making  organs,  such  as  the  spleen  and  lym- 
phatic glands,  are  often  enlarged.  The  blood-plaques,  or 
third  corpuscles,  are  found  to  be  present  in  increased  num- 
bers. These  blood-plaques  are  not  seen  in  moving  blood, 
but  are  found  in  blood-clot,  their  usual  proportion  to  red 
cells  being  as  i  to  20,  and  they  are  especially  numerous  at 
the  height  of  fever-processes  and  during  convalescence  from 
an  extensive  abscess. 

Chang-es  in  tlie  Perivascular  Tissues. — The  liquor 
sanguinis  which  exudes  during  an  acute  inflammation 
coagulates  unless  prevented  by  virulent  bacteria.  It  has 
often  been  asserted  that  exudation  is  Nature's  method  of 
supplying  nutriment  to  the  cells  of  the  damaged  region. 
Adami  points  out  the  apparently  contradictory  observation 
that  the  amount  of  exudate  is  in  direct  proportion  to  the 
rapidity  of  cell-destruction,  but  nevertheless  concludes  that 
exudation  stands  in  close  relation  with  cell-proliferation.^ 
From  whatever  cause,  tissue-cells  multiply,  and  this  process 
is  known  as  "  cell-proliferation." 

When  a  tissue  is  injured  it  inflames,  and,  as  Adami  points 
out,  the  reaction  to  injury  is  an  attempt  to  repair  injury. 

Irritation  may  lead  to  degeneration  and  death  of  cells ;  it 
may  lead  to  'growth  and  multiplication.  In  many  cases  both 
processes  are  active  in  the  acute  stage,  the  cells  at  the  focus 
of  the  inflammation  undergoing  degeneration  and  destruction, 

1  Allbutt's  System  of  Medicine. 


68  INFLAMMA  TION. 

and  those  at  the  boundary  undergoing  growth  and  proHfera- 
tion/ 

If  tissue-cells  have  been  seriously  damaged,  they  perish, 
and  new  cells  are  required  to  replace  them.  The  inflamma- 
tory process  has  led  to  exudation  of  plasma  and  migration  of 
leukocytes  into  the  perivascular  tissues.  The  connective- 
tissue  cells  multiply  and  produce  young  cells,  which  are 
known  as  "  fibroblasts,"  and  which  eat  up  many  leukocytes. 
The  migrated  leukocytes  in  part  move  out  of  the  inflamed 
area,  each  one  carrying  within  it  some  tissue-debris,  are  in 
part  eaten  up  by  the  fibroblasts,  in  part  undergo  degenera- 
tive changes,  and  a  very  few  of  them  multiply  and  give  rise 
to  fixed  cells.  This  mass  of  young  cells,  taking  origin 
chiefly  from  the  fixed  cells,  but  partly  from  the  leukocytes 
has  been  called  embryonic  tissue,  because  of  a  fancied 
resemblance  to  the  cells  of  the  embryo.  It  has  also  been 
called  indifferent  tissue,  because  of  the  belief  that  it  could 
be  converted  indifferently  into  various  tissues  according  to 
circumstances.  It  is  also  spoken  of  as  inflammatory  new 
formation. 

An  exudation  may  be  absorbed  by  the  lymphatics.  It  may 
be  converted  into  pus  if  infected  with  pyogenic  bacteria,  or 
be  replaced  by  cells  from  the  proliferation  of  fixed  tissue-cells 
and  leukocytes,  the  cellular  mass  being  subsequently  vascu- 
larized by  the  extension  into  it  of  capillary  loops  derived  from 
adjacent  capillaries.  When  embryonic  tissue  is  filled  with 
blood-vessels,  that  is  to  say,  when  it  is  vascularized,  it  is 
called  granulation-tissue.  Granulation-tissue  is  finally  con- 
verted into  fibrous  tissue.  The  above  complicated  proc- 
esses, vascular  and  perivascular,  are  not  accidents  nor  hap- 
hazard freaks,  but  are  Nature's  efforts  to  bring  about  a  cure. 

Dilatation  is  due  to  the  direct  effect  of  the  irritant  upon 
the  muscle  or  its  nerve-elements.  Retardation  and  stasis 
are  due  to  paralysis  of  the  vessel-wall,  which  paralysis 
causes  resistance  to  the  passage  of  the  blood-stream  and 
adhesion  of  the  leukocytes  to  the  vessel-wall.  The  blood 
liquor  exudes  and  the  leukocytes  migrate.  Often  these 
efforts  of  Nature  succeed.  Acceleration  of  the  circulation 
may  succeed  in  washing  away  an  irritant  from  the  vessel- 
wall.  By  bringing  quantities  of  blood  to  the  part  it  se- 
cures copious  exudation  of  plasma.  The  exudation  may 
wash  away  and  remove  irritants  from  the  tisslies,  and  the 
germicidal  blood-liquor  may  destroy  bacteria  in  the  damaged 
area.     The  migration  of  corpuscles  may  prove  of  great  ser- 

'  Adami,  in  AUbutt's  System  of  Medicine. 


CLASSIFICATION  OF  INFLAMMATIONS.  69 

vice.  The  leukocytes  surround  an  area  of  infection  and  tend 
to  limit  its  spread.  Leukocytes  have  phagocytic  properties, 
and  energetically  attack  and  often  destroy  bacteria,  and  they 
furnish  antitoxins  which  antagonize  and  may  neutralize  the 
poisons  produced  by  micro-organisms.  Leukocytes  aid  in 
separating  dead  tissue  from  living,  and  remove  tissue-debris 
from  the  area  of  inflammation.  Further,  they  may  contribute 
to  repair,  by  undergoing  multiplication  and  furnishing  young 
cells  which  are  not  wandering,  but  fixed.  The  multiplica- 
tion of  the  fixed  connective-tissue  cells  leads  to  the  forma- 
tion of  fibroblasts,  and  fibroblasts  are  converted  into  fibrous 
tissue,  which  effects  permanent  repair  (these  changes  will  be 
alluded  to  again  in  the  chapter  on  Repair). 

Nature  may  fail  in  her  efforts.  For  instance,  an  enormous 
exudate  increases  stasis  and  may  cause  such  tension  that 
gangrene  results. 

Inflammation  in  Non-vascular  Tissue. — A  type  of 
non-vascular  tissue  is  the  cornea,  and  the  cornea  can  inflame. 
The  healthy  cornea  contains  no  blood-vessels.  It  is  formed 
of  many  layers  of  fibers,  each  laj^er  running  parallel  with  the 
corneal  surface  and  forming  angles  with  the  fibers  of  the  adja- 
cent layers.  Between  the  layers  are  communicating  lymph- 
spaces  containing  connective-tissue  cells.  When  the  cornea 
inflames  the  episcleral  vessels  usually  dilate  and  pour  out 
exudate,  and  the  fluid  exudate  and  the  leukocytes  enter  into 
the  corneal  lymph-spaces.  The  exudate  coagulates  and  cell- 
multiplication  ensues  as  in  any  other  inflammation.  In  mild 
inflammations  the  episcleral  vessels  may  not  dilate.  Leuko- 
cytes, from  the  lymph-spaces,  reach  the  seat  of  injury  in 
small  numbers,  but  the  fixed  cells  and  possibly  some  leuko- 
cytes multiply.  Nancrede  points  out  that  in  trivial  inflam- 
mation which  injures  but  does  not  destroy  the  epithelium 
leukocytes  may  not  go  to  the  seat  of  inflammation,  the  only 
change  being  enlargement  and  multiplication  of  corneal  cor- 
puscles. If  new  formation  takes  place,  a  permanent  opacity 
mars  the  cornea  as  a  consequence.  When  cartilage  inflames 
it  becomes  filled  with  leukocytes,  which  are  obtained  from 
the  vessels  of  the  synovial  membrane  or  the  bone,  and 
changes  ensue  identical  with  those  previously  studied. 

Classification  of  Inflammations. — The  various  forms 
of  inflammations  are — (i)  Simple  ox  connnon,  that  which  is 
due  to  any  ordinary  traumatic,  chemical,  or  thermal  cause, 
and  not  to  bacteria,  such  as  traumatic  periostitis  or  sun  der- 
matitis. It  does  not  tend  particularly  to  spread.  As  a  rule, 
the  cause  of  a  simple  inflammation  is  momentary  in  action ; 


70  INFLAMMA  TION. 

(2)  infective  or  specific,  that  wliich  is  due  to  micro-organisms, 
as  the  streptococcus  of  erysipelas.  An  unsuccessful  attempt 
has  been  made  to  charge  all  inflammations  to  bacteria.  It  is 
true  that  bacteria  can  generally  be  found  in  inflammatory 
areas,  but  that  they  are  the  only  causes  of  inflammation  is 
accepted  by  few.  Infective  inflammations  often  tend  to  spread 
widely;  (3)  trainnatic,  which  is  due  to  a  blow  or  an  injury; 
(4)  idiopathic,  which  is  without  an  ascertainable  cause. 
There  is  certainly  a  cause,  even  if  it  cannot  be  pointed  out, 
and  the  term  "  idiopathic  "  means  that  we  do  not  know  the 
cause ;  (5)  acute,  which  is  rapid  in  course  and  violent  in 
action ;  (6)  chronic,  which  follows  a  prolonged  course  ;  (7) 
subacute,  which  is  intermediate  in  violence  and  duration  be- 
tween acute  and  chronic ;  (8)  sthenic,  characterized  by  high 
action.  Occurs  in  strong  young  subjects ;  (9)  asthenic  or 
adynamic,  occurring  in  the  old,  the  debilitated,  and  the 
broken-down.  In  such  an  inflammation  there  is  no  certain 
limitation  of  the  inflammation  by  leukocytes,  and  there  is 
an  indisposition  on  the  part  of  the  tissue-cells  to  form  fibro- 
blasts; (10)  parenchymatous,  affecting  the  "parenchyma," 
or  active  cells  of  an  organ;  (11)  interstitial,  affecting  the 
connective-tissue  stroma  of  an  organ;  (12)  serous,  char- 
acterized by  profuse  non-coagulating  exudation,  as  in  pleur- 
itis,  or  by  marked  inflammatory  edema;  (13)  plastic,  adhe- 
sive, or  fibrinous,  characterized  by  an  exudation  which  glues 
together  adjacent  surfaces,  as  in  peritonitis;  {i/[)  purident, 
phlegmonous,  or  suppurative,  when  the  pus  cocci  are  pres- 
ent and  multiply;  (15)  hemorrhagic,  when  the  exudate 
contains  many  red  blood-cells,  as  in  strangulated  hernia 
and  in  the  pustules  of  black  small-pox;  (16)  croupous,  when 
an  inflammation  produces  upon  the  surface  of  a  tissue 
a  fibrinous  exudate  which  cannot  be  organized  into  tissue, 
and  which  is  due  to  the  action  of  micro-organisms.  An 
exudate  of  this  character  was  called  by  the  older  surgeons 
"  aplastic  lymph."  It  occurs  most  usually  on  mucous  mem- 
brane ;  (17)  diphtheritic,  which  differs  from  croupous  in  the 
fact  that  the  false  membrane  is  in  the  tissue  rather  than 
upon  it;  {\^)  gangrenous,  an  inflammation  resulting  in  death 
of  the  part,  the  gangrene  being  due  to  the  tension  of  the 
exudate  or  the  violence  of  the  poison;  (19)  healthy,  when 
the  tendency  is  to  repair ;  (20)  unhealthy,  when  the  ten- 
dency is  to  destruction  ;  (21)  latent,  an  inflammation  which 
for  some  time  does  not  announce  itself  by  any  obvious 
symptoms,  as  the  inflammation  of  Peyer's  patches  in  typhoid 
fever;  (22)  contagious,  when  its  own  secretions  can  propa- 


CAUSES   OF  IXFLAMMATION.  y\ 

gate  it ;  (23)  dry,  without  exudation  ;  (24)  hypostatic,  arising 
in  a  region  of  passive  congestion  (as  a  bed-sore) ;  (25)  malig- 
nant, due  to  malignant  growths ;  (26)  cataj-rJial,  affecting 
mucous  membranes  ;  (27)  neuropathic,  due  to  impairment 
of  the  trophic  functions  of  the  nervous  system,  as  in  perfor- 
ating ulcer;  and  (28)  sympathetic  or  reflex,  due  to  disease 
or  injury  of  a  distant  part,  as  when  orchitis  follows  mumps. 

Extension  of  Inflammation. — Inflammation  extends 
by  continuity  of  structure,  b\'  contiguity  of  structure,  by  the 
blood,  and  by  the  lymphatics.  Extension  by  continuity  is 
seen  in  phlebitis.  Extension  by  contiguit}^  is  seen  when  a 
cutaneous  inflammation  adv^ances  and  attacks  deeper  struct- 
ures. Extension  by  the  blood  is  seen  in  the  formation  of 
the  small-pox  exanthem.  Extension  by  the  lymphatics  is 
witnessed  in  a  bubo  following  chancroid. 

Terminations  of  Inflammation. — Inflammation  may 
be  followed  by  a  return  of  the  tissues  to  health,  and  this 
return  may  take  place  by  delitescence,  by  resolution,  or  by 
new  growth.  By  delitescence  is  meant  abrupt  termination  at 
an  early  stage,  as  when  a  quinsy  is  aborted  by  the  ad- 
ministration of  quinin  and  morphin,  and  the  production  of  a 
sweat ;  resolutioJi  means  the  gradual  disappearance  of  the 
symptoms  when  inflammation  has  passed  through  its  regular 
stages  ;  and  netu  groii'th  means  that  an  inflammation  has 
lasted  a  considerable  time,  with  ample  blood-supply,  and 
without  suppuration  has  gone  on  to  the  formation  of  fibro- 
blasts, granulation-tissue,  and  fibrous  tissue.  Inflammation 
may  be  followed  by  death  of  the  inflamed  part,  or  necrosis. 
Death  of  the  part  may  be  due  to  suppuration,  ulceration,  or 
gangrene. 

The  causes  of  inflammation  ^ive^predisposing,  or  those 
residing  in  the  tissues,  and  rendering  them  liable  to  inflame ; 
and  exciting,  or  those  which  directly  awake  the  process  into 
activity.  The  first  may  be  thought  of  as  furnishing  inflam- 
mable material ;  the  second  may  be  regarded  as  sparks  of 
fire. 

Predisposing  causes  are  those  which  impair  the  general 
vigor,  injure  the  blood,  weaken  the  tissues,  or  lower  nutri- 
tive activities.  Among  these  causes  are  shock,  hemorrhage, 
nervous  irritation,  gout,  rheumatism,  diabetes,  Bright's  dis- 
ease, alcoholism,  and  syphilis.  Plethora  renders  a  person 
liable  to  sthenic  inflammations  (those  characterized  by  high 
action).  Tissue-debilit}'  renders  one  prone  to  adynamic  or 
asthenic  inflammations. 

Exciting  Causes. — The  excitino-  causes  of  inflammation  are 


72  INFLAMMA  TION. 

— tramnatic,  as  blows  and  mechanical  irritation  ;  chemical,  as 
the  stings  of  insects,  ivy  poison,  etc. ;  thermal,  heat  and  cold  ; 
and  specific,  the  micro-organisms,  causing,  for  instance,  tuber- 
cular peritonitis  or  erysipelas. 

Some  writers  insist  that  every  inflammation  is  due  to  the 
action  of  micro-organisms,  but  this  statement  lacks  proof 
They  maintain  that  inflammation  is  a  destructive  microbic 
process  which  cannot  bring  about  repair,  and  that  repair 
only  begins  when  inflammation  ends.  As  Adami  points  out, 
the  advocates  of  this  view  argue  that  swelling,  pain,  and  dis- 
coloration point  to  the  existence  of  inflammation  ;  that  repair 
can  take  place  when  these  phenomena  are  absent,  hence 
inflammation  is  not  present  when  repair  begins.  As  a  matter 
of  fact,  swelling,  discoloration,  and  pain  are  phenomena  often 
but  not  invariably  associated  with  inflammation ;  and  in 
inflammation  one  or  all  of  these  phenomena  may  be  absent. 
Because  these  signs  are  not  discovered  is  no  proof  that  in- 
flammation does  not  exist.  We  believe  that  inflammation  is 
not  always  due  to  microbes  and  is  not  always  a  destructive 
process,  but  may  be  from  the  start  conservative  and  repara- 
tive. It  is  the  reaction  of  the  tissue  to  injury  and  is  the  first 
step  on  the  road  to  repair.^ 

Symptoms  of  Acute  Inflammation. — Inflammation, 
if  at  all  severe,  announces  its  presence  b\'  s}-mptoms  which 
are  both  local  and  constitiitional.  The  local  s\'miptoms  are 
heat,  pain,  discoloration,  swelling,  and  disordered  function ; 
the  chief  constitutional  symptom  is  fever. 

Local  Symptoms  of  Inflammation. — The  most  promi- 
nent local  symptoms  were  known  centuries  ago  to  the 
famous  Roman  Celsus,  who  stated  them  as  "  rubor,  calor  cum 
tumore  et  dolore" — redness  and  heat  with  swelling  and  pain. 
As  set  forth  to-day,  the  local  symptoms  are — (i)  heat;  (2) 
pain;  (3)  discoloration;  (4)  sweUing ;  and  (5)  disordered 
function. 

Heat  is  due  to  the  passage  of  an  increased  quantity  of 
blood  through  the  damaged  area  and  to  the  arrival  at  the 
surface  of  the  body  of  warm  blood  from  internal  parts.  Al- 
though an  inflamed  part  may  be,  and  usually  is,  warmer 
than  the  surrounding  parts,  its  temperature  is  never  greater 
than  the  temperature  of  the  blood.  This  increase  of  heat  is 
especially  noticeable  when  we  contrast  the  feeling  of  an  arm 
affected  with  erysipelas  with  a  sound  arm ;  the  diseased  arm 
feels  much  warmer,  but  still  its  temperature  is  not  above  the 
general  body-temperature.     The  extremities  in  health,  as  is 

1  See  Adami's  masterly  article  in  Allbutt's  System  of  Medicine. 


LOCAL    SYMPTOMS   OF  L\'FLAMMATION.  J^ 

well  known,  show  on  the  surface  a  temperature  below  that 
of  the  blood ;  in  an  inflamed  state  their  temperature  may 
nearh'  equal  that  of  the  blood.  Heat  is  always  present  in 
inflammation  of  a  superficial  part.  The  surgeon  examines 
for  heat  by  placing  his  hand  upon  the  suspected  area  and 
then  placing  it  upon  a  corresponding  portion  of  the  opposite 
side  of  the  patient,  in  order  to  note  the  contrast.  If  great 
accuracy  is  desired,  a  surface  thermometer  is  used. 

Pai)i  is  a  constant  and  a  conspicuous  symptom.  It  is  due 
to  stretching  of  or  pressure  upon  nerves  from  exudate;  to 
irritation  of  nerves  ;  or  to  inflammation  of  the  nerves  them- 
selves, producing  cellular  changes.  Pain  is  associated  with 
tenderness  (pain  on  pressure),  it  is  aggravated  by  motion 
and  b}"  a  dependent  position  of  the  part,  and  it  varies  in 
degree  and  in  character.  In  serous  membranes  it  is  acute 
and  lancinating,  like  dagger-thrusts  ;  in  connective  tissue  it 
is  acute  and  throbbing ;  in  large  organs  it  is  dull  and  heavy ; 
in  the  bone  it  is  gnawing  or  boring ;  in  the  skin  and  mucous 
membrane  it  is  itching,  burning,  smarting,  or  stinging;  in 
the  urethra  it  is  scalding ;  in  the  testicle  it  is  sickening  or 
nauseating ;  in  the  teeth  it  is  throbbing ;  and  in  inflamma- 
tion  under  tense  fascia  it  is  pulsatile.  Pain  in  inflammation 
after  presenting  itself  in  one  form  may  change  in  character. 
If  a  pain  becomes  markedly  throbbing,  suppuration  may 
be  anticipated.  Pain  does  not  always  occur  at  the  seat  of 
trouble,  but  may  be  felt  at  some  distant  point.  This  is 
known  as  a  "  s}-mpathetic  "  pain,  and  means  that  a  nervous 
communication  exists  between  the  inflamed  part  and  a  distant 
area,  a  nerve-trunk  referring  pain  to  its  peripheral  distribu- 
tion. Tenderness,  however,  is  detected  at  the  seat  of 
trouble. 

Pain  of  hepatitis  is  often  felt  in  the  right  shoulder.  Pain 
at  the  point  of  the  shoulder  is  felt  also  in  gall-stones  and 
in  cancer  of  the  liver.  The  pain  arises  in  filaments  of  the 
pneumogastric  from  the  hepatic  plexus,  which  filaments 
reach  the  spinal  accessory,  pain  being  expressed  in  the 
branches  of  the  spinal  accessory  which  supply  the  trapezius 
and  communicate  with  the  third  and  fourth  cervical  nerves.^ 

Pain  of  coxalgia  is  often  felt  on  the  inside  of  the  knee, 
because  the  obturator  nerve,  which  sends  a  branch  to  the 
ligamentum  teres,  also  sends  a  branch  to  the  interior  and 
to  the  inner  side  of  the  knee-joint. 

Inflammation   of  an    eye  with    increased    tension    causes 

1  Embleton's  view  in  Hilton  on  Rest  and  Pain,  a  book  every  student  should 
read. 


74  INF  LA  MM  A  TION. 

brow-ache.  Inflammation  of  the  neck  of  the  bladder  causes 
pain  in  the  head  of  the  penis.  Inflammation  of  a  testicle 
causes  pain  in  the  groin.  Renal  calculus  and  pyelitis  cause 
pain  in  and  retraction  of  the  testicle,  and  pain  in  the  loin, 
groin,  or  thigh. 

If  the  covering  of  an  organ  is  involved,  pain  becomes 
more  violent ;  for  instance,  hepatitis  becomes  much  more 
painful  when  the  perihepatic  structures  are  attacked.  In- 
flammation without  pain  is  known  as  "  latent  "  (as  the  inflam- 
mation of  Peyer's  patches  in  typhoid).  The  sudden  disap- 
pearance of  inflammatory  pain,  when  not  due  to  opiates, 
suggests  the  possibility  of  gangrene,  because  analgesia  exists 
in  gangrene.  The  characteristics  of  inflammatory  pain  are 
that  it  comes  on  gradually,  has  a  fixed  seat,  is  continuous,  is 
attended  by  other  inflammatory  symptoms,  and  is  increased 
by  motion,  by  pressure,  and  by  the  hanging  down  of  the 
part.  If  there  be  no  tenderness  in  a  part,  the  source  of  the 
pain  is  not  local  inflammation ;  but  tenderness  may  exist 
when  there  is  no  local  inflammation,  as  in  pain  referred  from 
a  distant  part.  Pain  of  inflammation  does  not  correspond  to 
an  exact  nervous  distribution.  If  pain  corresponds  exactly 
to  the  area  of  a  nerve's  distribution,  the  cause  of  it  is  acting 
on  the  nerve-trunk  or  on  its  roots.  If  the  cutaneous  surface 
is  involved,  the  lightest  touch  causes  pain.  If  touching  the 
skin  produces  no  pain,  but  deep  pressure  does  produce  it, 
the  deeper  structures  are  the  source.  Pain  in  muscle  and 
ligament  is  developed  by  motion  :  in  muscle,  by  contraction, 
but  not  by  passive  movements  with  the  muscle  relaxed ;  in 
ligament  pain  is  developed  by  active  or  passive  movements 
which  stretch  the  ligament.  If,  for  example,  a  man  with  a 
stiff  neck  has  pain  on  the  right  side  of  the  back  of  his  neck 
on  voluntarily  turning  his  face  toward  the  left  shoulder,  but 
is  without  pain  when  his  face  is  turned  by  the  surgeon,  who, 
conversely,  induces  pain  by  turning  the  patient's  face  far  to 
the  right,  this  condition  indicates  the  trouble  to  be  muscular. 
If,  hoAvever,  no  pain  arises  on  turning  the  face  to  the  right, 
but  it  is  manifest  on  turning  the  face  actively  or  passively  to 
the  left,  the  pain  is  in  those  ligaments  which  stretch  when 
the  face  is  turned  to  the  left.^  In  inflammation  of  the  syno- 
vial membrane  gentle  passive  motion  in  any  direction  causes 
pain. 

The  pain  of  colic  differs  from  that  of  inflammation.  It  is 
sudden  in  onset,  intermits,  recurs  in  paroxysms,  and  is  re- 
lieved by  pressure.     The  pain  of  inflammation  is  gradual  in 

1  Surgical  Diagnosis,  by  A.  Pearce  Gould. 


LOCAL    SYMPTOMS   OF  LNFLAALMATLOiV.  75 

onset,  is  continuous,  and  is  made  worse  by  pressure.  The 
pain  of  neuralgia  is  often  preceded  by  cutaneous  anesthesia 
of  the  skin  of  the  part,  is  very  paroxysmal,  comes  on  sud- 
denly, darts  through  recognized  nerve-areas,  lasts  some 
hours,  and  is  apt  to  recur  at  a  certain  hour.  It  presents  no 
general  tenderness,  as  does  inflammation,  but  we  may  find 
several  points  which  are  acutely  sensitive  to  pressure  (Val- 
leix's  points  douloureux).  The  tender  spots  of  Valleix  are 
met  with  in  i)ivctcratc  neuralgia,  and  occur  at  points  where 
nerves  "  pass  from  a  deeper  to  a  more  superficial  level,  and 
particularly  where  they  emerge  from  bony  canals  or  pierce 
fibrous  fasciae."^ 

Pain  is  often  of  great  value  by  calling  attention  to  parts 
diseased ;  but  it  may  be  a  terrible  evil,  racking  the  organism 
and  even  causing  death.  If  pain  continue  long,  it  becomes 
in  itself  formidable :  it  prevents  sleep,  it  destroys  appetite, 
and  it  deteriorates  the  mind,  and  one  of  the  surgeon's  highest 
duties  is  to  relieve  it.  The  physiognomy  or  expression  of 
physical  pain  presents  the  following  characteristics  :  Heavy 
fulness  about  the  eyes,  and  dropping  of  the  angles  of  the 
mouth,  added  to  appearances  due  to  anemia,  widespread 
tremor,  etc.  The  absence  of  the  physiognomy  of  pain  in  a 
person  who  complains  of  great  agony  is  a  strong  indication 
that  the  patient  exaggerates  the  gravity  of  his  sufferings  or 
deliberately  deceives. 

Discoloration  arises  from  determination  of  blood  to  the 
part ;  hence  the  more  vascular  the  tissue  the  greater  the 
discoloration.  A  non-vascular  tissue  presents  no  discolora- 
tion, though  we  usually  find  discoloration  adjacent  in  the 
zone  of  blood-vessels  which  furnish  the  tissue  with  nutri- 
ment. Discoloration  is  most  intense  at  the  focus  or  center 
of  inflammatory  action.  Discoloration  varies  in  tint  and  in 
character  according  to  the  tissue  implicated  and  the  nature 
of  the  inflammation.  It  may  be  circumscribed  or  diffuse. 
Arborescent  redness  means  a  distribution  in  dendritic  lines. 
Linear  discoloration  signifies  redness  running  in  straight 
lines,  as  in  phlebitis.  Punctiform  discoloration  occurs  in 
points,  and  is  due  to  vascular  rupture.  Maculiform  redness 
resembles  an  ecchymosis  or  blotch.  Dusky  discoloration 
points  to  suppuration. 

Inflammation  of  the  throat  and  skin  produces  scarlet  dis- 
coloration ;  inflammation  of  the  sclerotic  coat  of  the  eye  and 
of  the  fibrous  coat  of  muscle  produces  lilac  or  bluish  discol- 
oration ;  inflammation  of  the  iris  produces  brick-dust,  gray- 

^  Anstie,  Xeuralgia  and  Diseases  whick  Resemble  Lt. 


76  IN  FLA  MM  A  TION. 

ish,  or  brown  discoloration ;  erysipelas  causes  a  yellowish- 
red  discoloration ;  secondary  syphilis  causes  a  copper-hued 
discoloration  ;  and  tonsillitis  causes  a  livid  discoloration.  A 
tubercular  ulcer  is  of  a  purple  colo-r  on  the  edge.  Gangrene 
is  shown  by  a  black  discoloration.  A  scorbutic  ulcer  is  sur- 
rounded by  an  area  of  violet  color. 

Redness  as  a  sign  of  inflammation  must  be  permanent 
and  joined  with  other  symptoms.  Redness  due  to  inflam- 
mation disappears  on  pressure,  but  returns  as  soon  as  the 
pressure  is  removed.  If  redness  is  due  to  staining  of  the 
surface  by  dye,  pigmentation,  or  extravasation  of  blood,  press- 
ure will  not  blanch  the  spot.  If  on  taking  off  pressure  the 
redness  of  inflammation  rapidly  returns,  the  circulation  is  ac- 
tive; if,  on  the  contrary,  it  very  slowly  reappears,  the  circula- 
tion is  very  sluggish  and  gangrene  is  threatened.  Subcuta- 
neous hemorrhage  gives  rise  to  a  purple-red  color  which 
does  not  fade  when  subjected  to  pressure.  Stains  of  the 
surface  by  dyes  fail  to  disappear  on  pressure,  are  distributed 
over  a  considerable  surface,  show  a  hue  which  is  uniform 
throughout,  are  obviously  superficial,  are  not  associated  with 
other  signs  of  inflammation,  and  can  be  washed  away. 

A.  Pearce  Gould,  in  his  excellent  little  work  upon  Sur- 
gical Diagnosis,  tells  us  that  the  color  of  a  hyperemic  sur- 
face may  furnish  important  information.  Lividity  may  mean 
failure  of  the  heart  and  lungs,  or  simply  venous  congestion 
in  the  part.  In  lividity  from  obstruction  of  the  lungs  or 
heart  the  color  slowly  returns  after  pressure  has  driven  it 
out.  In  lividity  due  to  local  congestion  the  color  quickly 
returns  when  pressure  is  released  and  the  dilated  veins  are 
often  distinctly  visible. 

Swelling  or  tnviefaction  arises  in  small  part  from  vascular 
distention,  but  chiefly  from  effusion  and  cell-multiplication. 
The  more  loose  cellular  material  a  part  contains,  the  more  it 
swells  ;  hence  the  eyelids,  scrotum,  vulva,  tonsils,  glottis,  and 
conjunctivae  swell  very  largely  when  inflamed.  A  swelling 
is  soft  or  edematous  v/hen  due  to  uncoagulable  effusion ;  is 
brawny  and  doughy  when  due  to  coagulated  effusion  ;  is 
hard  and  elastic  when  produced  by  proliferating  cells. 
Swelling  may  do  good  by  unloading  the  vessels  and  acting 
like  a  blister  or  local  bleeding,  or  it  may  do  great  harmby 
pressing  upon  the  vessels  and  cutting  off  the  blood-supply. 
Swelling  of  the  conjunctiva,  or  chemosis,  may  cause  slough- 
ing of  the  cornea,  and  swelling  of  the  prepuce  may  cause 
gangrene.  A  swelling  may  do  harm  by  obstruction  of  a 
natural  passage,  as  in  edema  of  the  glottis,  when  the  larynx 


COA'S  m  'UTIONA  L    S  YMP  TOMS.  J  / 

becomes  blocked;  or  by  compression  of  a  normal  channel, 
as  in  the  swelling  of  the  perineum,  when  the  urethra  is  com- 
pressed. A  swollen  area  may  be  covered  with  blisters  or 
blebs.     This  condition  is  noted  particularly  in  burns. 

Disordered  fu]ictio)i  is  always  present  in  inflammation. 
It  may  be  manifested  by  increased  tenderness  or  sensibility, 
a  sHght  touch,  it  may  be,  producing  torturing  pain.  Parts 
almost  or  entirely  destitute  of  feeling  when  healthy  (as  ten- 
dons, ligaments,  and  bones)  become  highly  sensitive  when 
inflamed.  It  may  be  manifested  by  increased  irritability.  In 
dysentery  the  colon  constantly  contracts  and  expels  its  con- 
tents ;  the  stomach  does  likewise  in  gastritis ;  and  the  blad- 
der acts  similarly  in  cystitis.  Spasmodic  twitching  of  the 
eyelids  occurs  in  conjunctivitis,  and  twitching  of  the  muscles 
in  fracture  and  after  amputation. 

Impairment  of  Special  Function. — In  inflammation  of  the 
eye,  when  an  attempt  is  made  to  look  at  objects,  the  lids 
close  spasmodically,  and  even  a  little  light  causes  great  pain 
and  lachrymation  (photophobia).  In  inflammation  of  the 
ear  noises  cause  great  suffering,  and  even  when  in  a  quiet 
room  the  patient  has  subjective  buzzing  and  roaring  sounds 
in  his  ears  (tinnitus  aurium).  In  coryza  the  sense  of  smell, 
in  glossitis  the  sense  of  taste,  in  dermatitis  the  sense  of  touch, 
and  in  laryngitis  the  voice  may  be  lost.  In  inflammation  of 
the  brain  the  mind  is  affected ;  in  arthritis  the  joints  can 
scarcely  be  moved ;  and  in  myositis  it  is  difficult  and  painful 
to  employ  the  muscles. 

Derangement  of  Secretions. — In  dermatitis  the  sweat  is  not 
thrown  off;  in  hepatitis  bile  is  not  properly  secreted;  and  in 
nephritis  urea  is  not  satisfactorily  removed.  The  secretions 
may  undergo  important  changes  of  composition.  The  spu- 
tum in  pneumonia  is  rusty,  and  dysentery  causes  a  discharge 
of  bloody  mucus  (Gross). 

Derangement  of  Absorbents. — In  the  height  of  an  inflam- 
mation the  absorbents  are  blocked  and  clogged  by  coagu- 
lated fibrin,  and  they  cannot  perform  their  offices. 

Constitutional  symptoms  of  acute  inflammation  may  be 
absent,  and  often  are  in  moderate  or  limited  inflammations  ; 
but  in  severe,  extensive,  or  infective  inflammations  the  symp- 
tom-group known  2iS  fever  \s  certain  to  exist.  This  is  known 
as  symptomatic,  sympathetic,  or  inflammatory  fever,  and  it 
arises  in  non-septic  cases  from  the  absorption  of  aseptic 
pyrogenous  exudate  and  in  microbic  inflammations  from 
absorption  of  pyrogenous  toxic  products  of  bacterial  action. 
In    young    and    robust    individuals    an    acute   non-microbic 


78  INFLAMMA  TION. 

inflammation  causes  a  fever  characterized  by  full,  strong 
pulse,  flushed  face,  coated  tongue,  dry  skin,  nausea,  consti- 
pation, and  possibly  acute  delirium  (the  sthenic  type  of  the 
older  authors).  In  broken-down  and  exhausted  individuals 
an  ordinary  inflammation,  and  in  any  individuals  a  bacterial 
inflammation,  may  cause  a  fever  with  typhoid  symptoms  (the 
typhoid,  asthenic,  or  adynamic  type).  In  inflammatory  con- 
ditions the  leukocytes  are  markedly  increased  in  number, 
the  condition  being  spoken  of  as  leukocytosis  or  transient 
leukocythemia.  Blood-plaques  are  also  increased.  The 
fibrin-ferment  is  obtained  from  the  white  corpuscles ;  it  is 
liberated  as  the  corpuscles  break  up  in  the  exudate,  and 
acting  on  the  liquor  sanguinis  causes  the  union  of  calcium 
and  fibrinogen  and  the  formation  of  fibrin.  The  absorption 
of  fibrin-ferment  many  believe  causes  aseptic  fever  (page  115). 
Inflammatory  blood  contains  an  increased  amount  of  albu- 
min and  salts.  If  a  person  with  inflammatory  fever  is  bled, 
the  blood  coagulates  rapidly,  the  clot  sinks,  and  there  is 
found  on  the  surface  a  cup-shaped  coat,  made  up  of  liquor 
sanguinis  and  white  cells,  known  as  the  *' buffy  coat;"  but 
this  is  not  a  sign  of  inflammation,  and  occurs  normally  in  the 
blood  of  the  horse.  The  buffy  coat  forms  when  blood  con- 
tains a  great  number  of  leukocytes,  because  these  leukocytes 
sink  more  slowly  than  do  the  red  corpuscles.  Cupping  oc- 
curs because  the  white  corpuscles  sink  more  slowly  by  the 
sides  of  the  tube  than  far  from  the  sides. 

Chronic  Inflamraation. — This  condition  progresses  slowly 
and  does  not  produce  symptoms  of  severity  either  in  the 
part  or  the  body  at  large. 

Causes. — Blood-diseases,  as  rheumatism  and  gout ;  infec- 
tive diseases,  as  tuberculosis  and  syphilis ;  retained  pus  in  an 
ill-drained  abscess ;  blockage  of  the  duct  of  a  gland ;  the 
retention  of  a  foreign  body  in  a  part ;  the  flow  of  an  irritant 
secretion  (as  saliva  from  a  fistula) ;  repeated  identical  trau- 
matisms of  an  occupation,  etc.  W.  Watson  Cheyne  tells  us 
chronic  inflammation  is  not  due  to  the  ordinary  pyogenic 
organisms  (see  Cheyne's  article  in  Treves's  System  of  Siir- 
geryf). 

Tissue-changes. — These  changes  are  practically  the  same 
as  in  acute  inflammation,  but  take  place  far  less  rapidly.  It 
is  maintained  by  Cheyne  and  others  that  typical  granulation- 
tissue  does  not  form,  the  tissues  of  the  part  being  replaced 
by  fibrous  tissue.  The  amount  of  fibrous  tissue  produ-ced 
is  relatively  very  great.  This  tissue  may  cause  permanent 
thickening,  or  may  contract  and  thus  diminish  the  size  of  a 


TREA  TMEXT. 


79 


part.  Contraction  is  very  considerable  in  cirrhosis  of  the 
liver  and  in  interstitial  nephritis. 

Syni/^tonis. — Pain  varying  in  intensity  and  character  ;  ten- 
derness ;  great  sweUing,  which  in  some  cases  is  followed  by 
shrinking,  and  is  usually  indurated  or  brawny;  sometimes  heat, 
rarely  discoloration  unless  the  skin  is  itself  inflamed.  There 
are  no  constitutional  symptoms  attributable  purely  to  the  in- 
flammation. If  there  are  such  symptoms,  they  are  due  to 
the  disease  which  induced  the  inflammation  or  to  interference 
with  the  function  of  an  organ  because  of  the  fibrous  mass. 
(For  treatment  of  chronic  inflammation  see  articles  upon 
special  regions  and  particular  structures.) 

Treatment  of  Acute  Inflammation. — The  first  rule  in 
treating  an  inflammation  must  be  to  remove  the  excitine 
cause.  If  this  cause  is  a  splinter  in  the  part,  take  out  the 
splinter ;  if  it  is  a  foreign  body  in  the  eye,  remove  the 
foreign  body  ;  if  urine  is  extravasated,  open  and  drain  ;  take 
off  pressure  from  a  corn ;  pull  out  an  ingrown  nail ;  and 
remove  microbes  from  an  infected  area  by  exposing,  irrigat- 
ing, and  applying  antiseptics.  The  rule,  remove  the  cause, 
applies  to  a  chronic  as  well  as  to  an  acute  inflammation.  If 
the  cause  of  an  inflammation  was  momentary  in  action  (as 
a  blow),  we  cannot  remove  it,  for  it  has  already  ceased  to 
exist.  After  removing  the  cause,  endeavor  to  bring  about  a 
cure  by  local  and  constitutional  treatment. 

Local  Treatment  of  Inflammation. — It  must  be  remem- 
bered that  the  division  of  inflammation  into  stages  is  natural, 
and  not  artificial,  and  that  a  remedy  which  does  good  in 
one  stage  may  do  harm  in  another.  Certain  agents  are 
suited  to  all  stages  of  an  inflammation,  namely,  rest  and 
elcvatio7i. 

Physiological  rest  is  of  infinite  importance,  and  is  always 
indicated  in  acute  inflammation.  In  the  exercise  of  function 
blood  is  taken  to  a  part  and  an  existing  inflammation  is  aggra- 
vated. Further,  as  Billroth  has  pointed  out,  rest  prevents 
the  dissemination  of  infection,  because  motion  exposes  fresh 
surfaces  to  inoculation  and  breaks  down  protective  barriers 
of  leukocytes.  Its  principles  were  first  thoroughly  studied 
by  Hilton.^  The  means  of  securing  rest  differ  with  the 
structure  or  the  part  diseased.  When  rest  is  used,  do  not  em- 
ploy it  too  long.  Rest  in  ^t^^^  diminishes  the  amount  of  blood 
sent  to  an  inflamed  part  and  lessens  the  force  of  the  circula- 
tion, hence  it  antagonizes  stasis.  It  has  been  shown  that  the 
heart  beats  at  least  fifteen  times  per  minute  less  when  the 

1  Lectures  upon  Rest  and  Pain. 


8o  INFLAMMA  TIOiV. 

patient  is  recumbent  than  when  he  is  erect.  The  saving  of 
strength  and  the  benefit  of  the  local  condition  are  thus  seen 
to  be  enormous.  In  fact,  the  heart  saves  at  least  twenty-one 
thousand  beats  a  day.  In  every  severe  inflammation  insist 
on  the  patient  going  to  bed.  In  cerebral  concussion  rest  must 
be  secured  by  quiet,  by  darkness,  by  the  avoidance  of  stimu- 
lants and  meat,  by  the  application  of  ice  to  the  head,  and 
by  the  use  of  purgatives  to  prevent  reflex  disturbance  and 
the  circulation  of  poisons  in  the  blood.  In  inflamed  joiiits 
rest  must  be  obtained  by  proper  position,  associated  in  many 
cases  with  the  adjustment  of  splints  or  plaster  of  Paris,  or 
the  employment  of  extension. 

In  pleiiritis  partial  rest  can  be  secured  by  strapping  the 
affected  side  with  adhesive  plaster  or  by  using  a  bandage  or 
a  binder  to  limit  respiratory  movements.  \\\  fractures  Nature 
procures  rest  by  her  splints — the  callus — and  the  surgeon 
procures  rest  by  his  splints — firm  dressings,  or  exten- 
sion. In  cancer  of  the  rectum  and  intractable  rectitis,  a 
colostomy  secures  rest  for  the  inflamed  and  damaged  bowel. 
In  enteritis  opium  gives  rest  to  the  bowel  by  stopping  peri- 
stalsis. In  cystitis  rest  is  obtained  by  opium  and  belladonna, 
which  paralyze  the  muscular  fibers  of  the  bladder.  The  use 
of  the  catheter  gives  rest  to  the  bladder  by  removing  urine. 
A  cystotomy  allows  complete  rest  by  permitting  the  bladder 
to  suspend  its  function  as  a  reservoir  of  urine.  In  cystitis 
from  vesical  calculus  rest  is  obtained  by  cutting  or  crushing  the 
stone.  In  inflamed  mucous  membrane  rest  from  the  contact 
of  irritants  is  secured  by  touching  the  membrane  with  silver 
nitrate,  which  forms  a  protective  coat  of  coagulated  albumin. 
Opening  an  abscess  gives  its  walls  rest  from  tension.  In  in- 
flammations of  the  eye  light  must  be  excluded  to  obtain  com- 
plete rest,  but  tolerably  satisfactory  rest  is  given  in  some  cases 
by  the  use  of  glasses  of  a  peacock-blue  tint.  In  aneurism 
the  operation  of  ligation  cuts  off  the  blood-current  and  gives 
rest  to  the  sac.  In  hernia  the  operation  gives  rest  from 
pressure.  Instances  of  the  value  of  rest  could  indefinitely 
be  multiplied. 

Relaxation  is  in  reality  a  form  of  rest,  and  consists  in 
placing  the  part  in  an  easy  position.  In  synovitis  of  the  knee 
semiflexion  of  the  knee-joint  lessens  the  pain.  In  muscular 
inflammations  relaxation  relieves  the  pain. 

Elevation  partly  restores  circulatory  equilibrium.  K  felon 
is  less  painful  when  the  hand  is  held  up  in  a  sling  than  when 
it  is  dependent.  A  congestive  headache  is  worse  during  re- 
cumbency.    A  gouty  inflammation  in  the  great  toe  is  more 


TREA  TMEXT.  8 1 

painful  with  the  foot  lowered  than  when  it  is  raised.  A  tootli- 
achc  becomes  worse  on  lying  down. 

Certain  agents  are  suited  to  the  stage  of  vascular  engorge- 
ment, increased  arterial  tension,  and  beginning  effusion. 
These  agents  are — (i)  local  bleeding  or  depletion ;  (2J  cut- 
ting off  the  blood-supply  ;  and  (3)  cold. 

Local  bleeding,  or  dcplctioii,  is  the  abstraction  of  blood  from 
the  inflamed  area.  This  abstraction  relieves  circulatory  re- 
tardation and  causes  the  blood  to  move  rapidly  onward; 
the  corpuscles  clinging  to  the  vessel-walls  are  washed  away, 
the  capillaries  shrink  to  their  natural  size,  and  the  exudate 
is  absorbed.  In  other  words,  local  blood-letting  increases 
the  rate  of  the  circulation,  though  not  its  force. 

TJic  methods  of  bleeding  locally  are — (^7)  puncture;  {b) 
scarification ;  [c)  leeching ;  and  [d)  cupping. 

Puncture  is  recommended  in  inflammation,  not  only 
because  it  abstracts  blood  localh%  but  also  because  it  gives 
an  exit  to  effusion  under  fibrous  membranes.  It  is  very  use- 
ful in  relieving  tension — for  instance,  in  epididymitis.  It  is 
performed  with  a  tenotome  and  with  aseptic  precautions.  If 
numerous  punctures  are  made,  the  procedure  is  termed 
"multiple  puncture."  This  is  ven,' useful  when  applied  to 
the  inflamed  area  around  a  leg-ulcer.  The  late  Prof.  Joseph 
Pancoast  was  ver\'  fond  of  employing  multiple  punctures, 
designating  the  operation  "  the  antiphlogistic  touch  of  the 
therapeutic  knife." 

Scarification  or  Incision. — B}"  means  of  scarification  we 
bleed  locally,  evacuate  exudates,  and  relieve  tension.  One 
cut  or  many  cuts  may  be  made,  and  these  cuts  may  be  deep 
or  mav  not  go  entirelv  through  the  skin,  according  to  cir- 
cumstances.  Multiple  incisions  are  useful  when  applied  to 
inflamed  ulcers,  ulcers  in  danger  of  gangrene,  and  to  almost 
any  condition  of  great  tension.  Free  incision  is  of  great 
value  in  periostitis  and  in  threatened  gangrene.  In  osteo- 
myelitis the  medullar}'  canal  must  be  promptly  opened. 

Leeching. — Leeches  must  not  be  applied  to  a  region  plenti- 
fully endowed  with  loose  cellular  tissue,  as  great  swelling 
and  discoloration  are  sure  to  ensue.  These  regions  are  the 
prepuce,  labia  majora,  scrotum,  and  eyelids.  Leeches  should 
never  be  applied  to  the  face  (because  of  the  scar),  near 
specific  scars  or  inflammations,  nor  o\&v  a  superficial  arter}', 
vein,  or  nerve.  A  leech  is  best  applied  at  the  periphery 
of  an  inflammation  and  between  an  inflammation  and  the 
heart.  To  leech  at  the  inflammatory-  focus  only  aggravates 
the  trouble.      Before  apph-ing  leeches,  wash  the  part  and 

6 


82  INFLAMiMAriON. 

shave  it  if  hairy.  If  the  leeches  will  not  bite,  smear  the  part 
with  milk  or  with  a  little  blood.  In  using  a  leech,  place  it 
on  the  skin  under  a  glass  tube,  or  an  inverted  wine-glass. 
The  thick  end  of  the  leech  is  the  tail,  and  this  must  be  placed 
in  the  glass  first.  Never  pull  off  a  leech :  let  it  drop  off;  and 
if  it  refuses  to  do  so,  sprinkle  it  with  salt.  After  removing  a 
leech,  employ  warm  fomentations  if  continued  bleeding  is  de- 
sired. Sometimes  the  bleeding  persists,  but  this  may  be  ar- 
rested by  styptic  cotton  and  pressure.  In  some  rare  cases  the 
bleeding  continues  in  spite  of  pressure.  This  is  due  to  the  fact 
that  the  tissue  contains  a  considerable  quantity  of  a  material 
from  the  throat  of  the  leech,  which  material  prevents  coagula- 
tion of  blood.  In  such  a  case  excise  the  bite  and  the  area  of 
tissue  adjacent  to  it,  and  suture  the  wound.  Leeching  leaves 
■permanent  triangular  scars.  The  Swedish  leech,  which  is 
preferred  to  the  American,  draws  from  two  to  four  drams 
of  blood.  After  a  leech  has  been  removed,  if  we  desire  to 
use  it  again,  place  it  in  salt  water.  This  causes  it  to  vomit 
the  blood  which  it  has  taken  up.  Leeching  has  both  a  con- 
stitutional and  a  local  effect.  It  is  at  the  present  time  used 
comparatively  rarely,  but  it  is  employed  by  some  practitioners 
over  the  spermatic  cord  in  epididymitis,  on  the  temple  in 
ocular  inflammation,  and  over  the  right  iliac  region  to  relieve 
the  pain  in  mild  cases  of  appendicitis. 

Clipping. — Dry  cups  deviate  blood  from  a  deeply  placed 
inflamed  area  to  the  surface.  Wet  cups  actually  remove 
blood. 

Dry  Qips. — Dry  cups  are  applied  without  first  incising  the 
skin.  One  or  many  may  be  applied.  A  special  instrument 
is  sold  in  the  shops  for  the  performance  of  dry  cupping.  It 
consists  of  a  glass  bell,  with  a  globular  and  hollow  top  of 
rubber.  The  rubber  bulb  is  emptied  of  air  by  squeezing, 
the  glass  bulb,  the  edges  of  which  have  been  greased,  is 
pushed  upon  the  skin  and  the  compression  is  relaxed  upon 
the  bulb.  A  partial  vacuum  is  created,  and  an  area  of  skin 
and  subcutaneous  tissue  full  of  blood  rise  up  into  the  glass 
bell. 

Cupping  can  be  easily  performed  by  means  of  a  tumbler. 
The  edge  of  the  glass  is  greased  ;  a  bit  of  blotting-paper 
wet  with  alcohol  is  placed  in  the  bottom  of  the  tumbler  and 
lighted.  After  a  brief  period  the  glass  is  inverted  and  placed 
upon  the  skin,  which  has  been  dampened  with  warm  water. 
As  the  air  in  the  glass  cools  the  tissues  rise  up  into  the 
partial  vacuum. 

Wet  Clips. — Wet  cups  draw  blood,  and  the  skin  should  be 


TREA  TMENT. 


83 


cleansed  before  they  are  applied.  In  wet  cupping  apply 
a  cup  for  a  moment,  remove  it,  incise  or  puncture  the  skin, 
and  replace  the  cup  to  draw  the  requisite  amount  of  blood. 
Incisions  may  be  made  by  a  lancet 
or  scai-ificator,  a  cup  being  then  ap- 
plied. An  excellent  scarificator  is 
shown  in  Fig.  27.  In  this  instrument 
concealed  blades  are  thrown  out  b}- 
touching  a  spring.  Baron  Heurteloup 
devised  an  instrument  (Fig.  28)  in 
which  the  incision  is  made  by  a  scari- 
ficator. The  blood  is  drawn  b\-  a 
pump,  the  tube  being  placed  upon 
the  cut  area  and  the  withdrawal  of 
the  piston  creating  a  vacuum.  This 
instrument  is  known  as  the  "  arti- 
ficial leech."  After  scarification  and  the  application  of  the 
cup,  the  partial  vacuum  draws  blood  into  the  cup ;  when  the 
surface  ceases  to  bleed,  the  cup  is  removed,  and  if  further 
bleeding  is  thought  desirable,  the  clots  are  wiped  away  and 
the  cup  is  again  applied,  and  after  its  removal  warm  fomen- 
tations are  used  (Cheyne  and  Burghard).  Wet  cupping  is 
of  value  in  pleuritis,  pericarditis,  and  nephritis. 

Cutting  off  the  Blood-supply. — Onderdonk,  of  Xew  York, 
in  1 813  recommended  ligation  of  the  main  artery  of  a  limb 


Fig.  27. — Scarificator. 


Fig.  2S. — Heurteloup'i  artificial  leech. 


for  the  cure  of  inflammation  in  important  structures  supplied 
b\'  the  vessel.  The  procedure  was  warmly  advocated  by 
Campbell,  of  Georgia,  for  the  treatment  of  gunshot-wounds 
of  joints.  This  plan  of  treatment  is  now  not  to  be  considered 
for  a  moment ;  antisepsis  furnishes  us  with  a  safer  and  more 
certain  plan.  Vanzetti,  of  Padua,  advocates  digital  pressure 
to  cut  off  the  blood-supply  to  an  inflamed  part. 


84  INFLAMMA  TION. 

Cold  is  a  very  powerful  and  useful  agent  if  used  judiciously 
and  applied  at  the  proper  time.  It  is  valuable  because  of  its 
reflex  effect  upon  the  vessels  of  the  inflamed  area  rather 
than  because  of  direct  action  upon  the  cells  of  a  part.  It 
should  be  used  early  in  the  case,  before  stasis  occurs.  It 
is  not  to  be  used  in  the  later  stages  of  inflammation,  for  it 
will  then  only  aggravate  the  existing  state — in  fact,  when 
there  is  considerable  exudation  cold  does  no  good. 

Cold  acts  by  constricting  the  vessels  of  a  hyperemic  area, 
thus  lessening  the  amount  of  blood  sent  to  the  part,  antago- 
nizing stasis,  and  preventing  the  exudation  of  fluids.  Fur- 
ther, it  prevents  the  migration  of  leukocytes,  retards  cell- 
proliferation,  relieves  pain  and  tension,  and  lowers  tem- 
perature. If  cold  is  too  intense,  if  it  is  kept  too  long 
applied,  if  it  is  used  late  in  an  inflammation,  if  it  is  used 
upon  an  old  or  feeble  patient,  when  there  is  much  exu- 
dation or  a  condition  of  tissue  strangulation,  it  does  actual 
harm.  It  lessens  the  nutritive  activity  of  cells,  constricts 
the  lymph-spaces  and  channels,  favors  stasis,  and  hence 
lowers  the  vitality  of  the  tissues.  If  the  parts  are  con- 
stricted, as  in  hernia,  or  compressed  by  a  large  exudate,  or 
fed  by  diseased  blood-vessels,  cold  may  cause  gangrene. 
Nancrede,  in  his  Principles  of  Surgery,  points  out  that  in  an 
inflammation  stasis  soon  arises  at  the  focus  of  the  inflamma- 
tion, and  there  is  an  area  of  stasis  surrounded  by  a  zone  of 
hyperemia.  Cold  benefits  the  hyperemic  zone  but  aggra- 
vates the  stasis.  Nancrede  cautions  us  as  follows  :  "Judg- 
ment is  therefore  requisite  to  decide  whether  the  evil  at  the 
focus  will  not  outweigh  the  good  exerted  at  the  periphery.^ 
Nancrede  further  points  out  that  cold  must  not  be  used  inter- 
mittently; but  if  employed  at  all,  must  be  continuously 
applied.  If  cold  is  applied  intermittently,  there  will  be  a  re- 
action whenever  it  is  removed,  and  this  reaction  causes 
increased  hyperemia.  Hence,  cold  must  be  "  continued  in 
action  to  prevent  reaction."  If  during  the  employment  of 
cold  the  skin  becomes  purple  and  congested  and  the  circula- 
tion feeble,  at  once  discontinue  the  use  of  it,  as  its  continu- 
ance will  be  dangerous. 

Cold  may  be  used  as  wet  cold  or  as  dry  cold. 

Wet  Cold. — Wet  cold  is  easily  applied,  but  it  is  much  more 
depressing  than  dry  cold,  is  likely  to  produce  discomfort, 
macerates  the  skin,  and  may  lead  to  the  formation  of  excoria- 
tions, etc.  A  part  can  be  subjected  to  wet  cold  by  the 
application  of  evaporating  fluids   or  the   use   of    a   siphon. 

1  Priyiciphs  of  Surgeiy. 


TREATMEXT.  85 

When  wet  cold  is  used  inspect  the  part  at  frequent  intervals, 
and  discontinue  the  treatment  if  evidences  of  stasis  become 
positive.  Evaporating  fluids  are  extensively  employed.  If 
such  a  fluid  is  used,  never  cover  the  part  with  a  thick  dress- 
ing. If  this  should  be  done,  the  fluid  will  not  evaporate  with 
sufticient  rapidity  to  produce  cold.  A  piece  of  thin  muslin 
or  flannel  should  be  moistened  with  the  fluid  and  laid  upon 
the  part,  and  be  kept  constantly  moist  by  the  application 
from  time  to  time  of  small  quantities  of  the  liquid.  Lead- 
water  and  laudanum  is  used  extensively,  and  probably  owes 
its  chief  value  to  the  fact  that  it  produces  cold  on  evapora- 
tion. Lead-water  and  laudanum  is  composed  of  sj  of  lauda- 
num, 5J  of  liquor  plumbi  subacetatis,  and  i  pint  of  water. 
Liquor  plumbi  subacetatis  dilutus  may  be  used  without 
laudanum.  It  is  thought  that  the  addition  of  laudanum 
tends  to  allay  pain.  A  solution  of  ammonium  chlorid  may 
be  used  in  the  strength  of  5J  of  the  drug  to  2  quarts  of 
water.  If  ammonium  chlorid  is  used  for  more  than  a  short 
period  of  time,  it  is  prone  to  cause  the  formation  of  blisters 
which  are  irritable  and  painful.  Cheyne  and  Burghard 
use  the  following  formula :  \  ounce  of  ammonium  chlorid, 
I  ounce  of  alcohol,  and  7  ounces  of  water.  Plain  spring 
water,  iced  w^ater,  or  a  mixture  of  alcohol  and  water  may  be 
used.  The  siphon  is  occasionally  used.  If  there  is  a 
wound,  the  fluid  must  be  aseptic  or  antiseptic.  In  conjunc- 
tivitis, cold  is  applied  to  the  eye  by  means  of  linen  or  muslin 
soaked  in  iced  water  laid  upon  the  lid,  and  frequently  changed. 

To  apply  wet  cold  by  means  of  a  siphon,  the  part  is  cov- 
ered with  one  layer  of  wet  linen  or  muslin  and  is  laid  upon 
a  rubber  sheet  folded  like  a  trough  and  emptying  into  a 
bucket.  A  vessel  filled  with  cold  water  is  placed  upon  a 
higher  level  than  the  bed.  A  wet  lamp-wick  is  now  taken, 
one  end  is  inserted  into  the  water  of  the  vessel,  and  the  other 
end  is  laid  upon  the  part.  Capillary  action  and  gravity  com- 
bine to  keep  the  part  moist.  A  rubber  tube  may  be  used 
instead  of  a  wick.  If  a  tube  is  employed,  tie  it  in  a  knot  or 
clamp  it  so  that  the  fluid  is  delivered  drop  by  drop  (Fig.  29). 
Ordinary  w^ater  or  iced  water  can  be  used.  If  the  water  be 
too  warm,  it  can  be  reduced  to  about  45°  F.  by  adding  i 
part  of  alcohol  to  every  4  parts  of  water.  A  mixture  of  5 
parts  of  nitrate  of  potassium,  5  parts  of  chlorid  of  ammo- 
nium, and   16  parts  of  water  produces  great  cold. 

Dry  cold  is  more  manageable  and  more  generally  useful 
than  wet  cold.  It  is  applied  b\'  means  of  a  rubber  bag  or  a 
bladder  filled  with  ground  or  fineh'  cracked  ice,  several  folds 


86 


INFLAiMMA  TION. 


of  flannel  being  first  laid  over  the  part.  The  flannel  collects 
the  moisture  from  the  "  sweating "  bag  and  thus  prevents 
maceration  of  the  skin.  Further,  it  saves  the  tissue  from 
being  subjected  to  too  much  direct  cold  and  enables  us  to 
obtain  the  beneficial  reflex  effect.  The  ice-bag  of  India  rubber 
is  widely  used.  We  can  venture  to  apply  by  means  of  the 
ice-bag  a  greater  degree  of  cold  than  it  is  proper  to  apply  by 
the  use  of  fluids,  as  dry  cold  is  not  so  likely  to  induce  gan- 


FiG.  29. — Siphon  (Esmarch). 

grene  as  is  moist  cold.  If  there  is  much  tenderness,  the 
weight  of  an  ice-bag  causes  pain,  and  it  is  best  to  suspend 
it  from  a  frame,  so  that  it  lightly  touches  the  part.  The 
frame  is  the  same  as  is  used  to  keep  the  bedclothes  from 
a  fractured  leg,  and  is  made  from  barrel  hoops  (Fig.  143). 
During  the  time  an  ice-bag  is  being  used  the  part  must  be 
inspected  at  brief  intervals  to  see  that  the  circulation  is 
hot  unduly  depressed.  The  ice-bag  is  frequently  used 
in  joint-inflammation,  in  intracerebral  inflammation,  in  the 
early   stage    of  appendicitis,   in    epididymitis,  and    in    acute 


TREA  TMEXT. 


^7 


myelitis.  If  a  joint  is  sprained,  the  immediate  application 
of  an  ice-bag  is  of  great  service.  A  part  can  be  encir- 
cled with  a  rubber  tube  through  which  iced-water  is  made  to 
flow  (Fig.  30).  E\en  when  this  apparatus  is  used  the  part 
should  first  be  wrapped  in  flannel.  Leiter's  tubes,  which  are 
tubes  of  lead  made  to  fit  various  regions  and  which  carr}'  a 
stream  of  cold  water,  can  also  be  used.  A  piece  of  flannel 
must  be  placed  between  the  tube  and  the  skin.  The  tempera- 
ture of  these  tubes  can  be  lowered  to  any  desired  degree  by 
lowering  the  temperature  of  the  circulating  fluid.  Cheyne 
and  Burghard  caution  us  to  use  a  fluid  at  a  temperature  not 
under  50°  or  60°  F.,  to  inspect  the  part  e\-er}'  three  or  four 


Fig.  30. — The  Esmarch  cooling  coil. 

hours,  and  not  to  employ  the  tubes  longer  than  twent}'-four 
hours. ^ 

Ntc7t  is  emplo}'ed  by  some  early  in  an  inflammation.  It 
is  rarely  beneficial  at  this  stage,  except  when  applied  b}'  a 
hot-air  apparatus  for  the  treatment  of  an  injured  joint.  It 
is  true  that  a  degree  of  heat  which  does  not  actually  destroy 
the  tissues  will  contract  the  vessels  as  does  cold ;  but  this 
degree  of  heat  will  not  be  borne  by  the  patient,  and  will  not 
be  tolerated  unless  but  a  limited  portion  of  a  superficial  part 
is  involved. 

Certain  agents  are  suited  to  the  stage  of  fully  developed 

1  Matiual  of  Surgical  Treatment,  by  W.  Watson  Cheyne  and  F.  F.  Burg- 
hard. 


88  INFLAMMA  TION. 

inflammation,  Avhen  there  is  a  great  deal  of  swelling  due  to 
effusion  and  cell-proliferation.  The  indication  in  this  stage 
is  to  abate  swelling  by  promoting  absorption.  This  is  accom- 
plished by  (i)  compression;  (2)  the  local  use  of  astringents 
and  sorbefacients ;  (3)  the  douche;  (4)  massage;  and  (5) 
heat. 

Comp7'£ssion  is  especially  useful  in  fully  developed  or  in 
chronic  inflammation,  but  it  will  do  good  also  in  the  iirst 
stage.  Compression  is  of  great  usefulness ;  it  supports 
the  vessels  and  causes  them  to  drink  up  effusion,  and  it 
strongly  rouses  the  absorbents.  This  agent  is  valuable 
in  most  external  inflammations  with  much  swelling.  In 
erysipelas  of  an  extremity  the  part  should  be  elevated  and 
the  extremity  bandaged  from  the  periphery  to  the  body.  In 
ulcers,  especially  those  with  hard  and  blue  edges,  the  use 
of  Martin's  elastic  bandage  or  of  straps  of  adhesive  plaster 
gives  decided  relief.  In  chronic  inflammation  of  a  joint  elas- 
tic compression  is  of  great  value.  In  epididymitis,  after  the 
acute  stage,  the  testicle  may  be  strapped  with  adhesive  plas- 
ter. In  lymphadenitis  compression  by  a  weight  or  by  a 
bandage  is  very  generally  employed.  In  fractures  compres- 
sion not  only  antagonizes  spasm,  but  often  combats  the 
swelling  and  pain  of  inflammation.  Compression  must  be 
judicious  :  it  must  never  be  forcible,  and  it  must  not  be 
applied  to  a  limb  without  including  the  distal  extremity 
(never,  for  instance,  strongly  compress  the  elbow  without 
including  the  hand,  nor  the  palm  without  bandaging  the 
fingers).  Injudicious  compression  causes  severe  pain,  and 
may  produce  gangrene. 

Astringents  and  Sorbefacients. — Astringents  may  have 
direct  value  in  inflammation  of  the  skin,  but  it  is  not  likely 
that  they  have  any  effect  in  deep-seated  inflammation.  When 
used  in  evaporating  lotions  in  an  earlier  stage  of  inflamma- 
tion the  cold  does  good  rather  than  the  drug.  Lead-water 
and  laudanum  is  extensively  employed  and  it  is  thought  to 
somewhat  allay  inflammatory  pain.  The  mixture  is  certainly 
serviceable  in  cutaneous  erysipelas.  It  is  \&xy  doubtful  if 
lead-water  is  of  any  service  at  any  stage  of  a  deep-seated 
inflammation  or  in  any  fully  developed  inflammation.  If 
used  after  the  first  stage  it  must  not  be  applied  as  an  evap- 
orating lotion,  because  cold  will  do  harm.  Pieces  of  lint  are 
soaked  in  the  fluid  and  placed  upon  the  part,  and  a  bandage 
is  applied.  The  wet  lint  which  has  been  placed  upon  the  part 
is  covered  with  oiled  silk  or  a  rubber-dam  before  the  band- 
age is  applied.     If  used  in  the  latter  manner,  the  body  heat 


TREA  TMENT.  89 

is  retained  in  the  part.  If  greater  heat  is  desired,  a  hot-water 
bag  can  be  phiced  outside  of  the  bandage.  Lead-water  is 
not  used  in  treating  wounds. 

Tincture  of  iodinis  astringent,  sorbefacient,  counterirritant, 
and  antiseptic.  It  must  not  be  used  pure.  For  apphcation  to 
adults  it  should  be  diluted  with  an  equal  amount  of  alcohol, 
and  for  children  with  3  parts  of  alcohol.  In  using  iodin,  paint 
it  upon  the  part  with  a  camel's-hair  brush  and  fan  it  dry, 
applying  one  or  more  coats.  The  repeated  application  of 
iodin  to  the  skin  is  of  great  benefit  in  inflammation  of  the 
glands,  muscles,  tendons,  joints,  and  periosteum.  Iodin  is 
apt,  after  a  time,  to  vesicate,  and  must  not  be  used  in  full 
strength,  because  it  is  irritant.  It  is  of  especial  value  in 
chronic  inflammation.  In  deep-seated  inflammation  it  acts 
as  a  counterirritant. 

Nitrate  of  silver  is  a  non-irritating  astringent  of  considera- 
ble value  in  inflammation  of  mucous  membranes.  It  forms 
a  protective  coat  of  coagulated  albumin,  and  is  much  used 
in  treating  the  throat,  mouth,  and  genital  organs.  In 
urethral  inflammation  a  proteid  compound  of  silver  known 
as  protargol  may  be  used. 

Iclitliyol  is  a  drug  of  decided  efficiency  in  reducing  inflam- 
matory swelling.  It  is  usually  employed  in  ointments,  the 
strength  being  from  25  to  50  per  cent.  It  is  best  exhibited 
with  lanolin.  When  rubbed  in  over  inflamed  glands,  joints, 
and  lymphatic  enlargements  it  is  of  great  value.  In  children 
a  25  per  cent.,  and  in  adults  a  50  per  cent.,  ointment  should 
be  rubbed  in  thoroughly  twice  a  day.  In  inflammatory  skin- 
disease,  synovitis,  thecitis,  frost-bite,  bubo,  chilblain,  and  in 
many  other  conditions,  acute  or  chronic,  the  use  of  ichth}'ol 
is  indicated.  The  odor  of  ichthyol  is  highly  disagreeable,  and 
when  ordered  for  a  refined  person  it  had  better  be  deodor- 
ized. For  this  purpose  Hare  uses  oil  of  citronella,  Tllxx  to 
5j  of  ointment. 

Mercurials. — Blue  ointment,  pure  or  diluted  to  various 
strengths,  is  extremely  valuable.  It  is  spread  upon  lint 
and  kept  applied  over  areas  of  fully  developed  inflam- 
mation. It  is  especially  useful  in  acutely  or  chronically 
inflamed  joints,  glands,  tendons,  etc.  Blue  ointment  is 
strongly  irritant,  and  will  soon  blister  or  excoriate  a  tender 
skin.  It  is  very  beneficial  in  periostitis,  and  is  employed 
largely  in  chronic  inflammations. 

The  do2tche  consists  of  a  stream  of  water  falling  upon  a 
part  from  a  height.  The  water  may  be  poured  from  a 
receptacle  or  may  run  through  a  tube,  and  may  be  either 


90  INFLAMMA  TWN. 

hot  or  cold.  Alternating  hot  and  cold  streams  are  very- 
popular  in  inflammations  of  joints  and  tendons,  especially  in 
chronic  inflammation.  This  mode  of  application  is  known  as 
the  "  Scotch  douche."  It  restores  the  tone  of  the  blood-ves- 
sels and  plasma-channels  and  promotes  the  absorption  of 
inflammatory  exudate.  If  the  part  is  very  tender,  the  water 
should  be  squeezed  upon  it  from  sponges.  In  a  sprain  of 
the  knee-joint,  after  a  time,  when  thickening  has  occurred, 
pour  upon  the  part  daily,  from  a  height,  first  a  pitcherful  of 
very  hot  water,  then  a  pitcherful  of  very  cold  water ;  then 
use  friction  with  a  hand  greased  with  cosmolin.  Hot  vaginal 
douches  are  largely  employed  in  pelvic  inflammations. 

Massage  is  a  procedure  not  frequently  enough  employed. 
It  is  very  useful  in  some  acute  inflammations,  though  in 
these  it  must  be  gentle.  It  is  of  great  service  in  the  treat- 
ment of  sprains  of  joints  and  fractures.  It  is  influential  for 
good  in  chronic  inflammations  at  the  period  when  rest  is 
abandoned.  It  acts  by  promoting  the  movements  of  tissue- 
fluids  (blood,  lymph,  and  areolar  fluid),  stimulating  the 
absorbents,  strengthening  local  nervous  control,  and  thus 
improving  nutrition.  Passive  motion  in  joints  acts  as 
massage. 

Heat  may  be  used  continuously  or  intermittently,  and  may 
be  either  moist  or  dry.  A  considerable  degree  of  heat  will 
act  like  cold  and  contract  the  vessels.  The  degree  neces- 
sary to  cause  vascular  contraction  wovild  not  destroy  the 
tissue,  but  would  produce  discomfort,  which  discomfort 
would  become  unbearable  during  the  continuance  of  the 
application.  Therefore,  heat  is  rarely  used  in  the  earliest 
stage  of  an  acute  inflammation.  It  is  hard  to  state  ex- 
actly when  heat  should  be  substituted  for  cold.  Certainly 
after  a  day  or  two  it  is  preferable.  The  sensations  of  the 
patient  may  be  of  use  in  determining  this  point,  and  if  heat 
gives  comfort  it  may  be  used.  Moderate  heat  should  be 
used  when  inflammation  is  not  very  superficial.  In  a  cuta- 
neous inflammation  heat  usually  does  harm,  because  it  in- 
creases the  congestion  of  an  inflamed  superficial  part.  In 
deep-seated  inflammations  heat  to  the  surface  acts  as  a  re- 
vulsive or  counterirritant.  Thus  a  poultice  to  the  chest  may 
do  good  in  the  first  stage  of  pneumonia,  and  cauterization  of 
the  skin  over  a  joint  may  benefit  an  acute  synovitis.  The 
use  of  heat  for  purposes  of  counterirritation  will  be  discussed 
under  the  head  of  Counterirritants.  A  moderate  degree  of 
heat  applied  over  a  fully  developed  and  not  too  superficial 
inflamed  area  dilates  the  vessels,  especially  the  veins.     Thus 


TREATMENT.  9 1 

circulation  is  re-established  in  an  area  filled  with  stagnant 
blood  or  blood  which  is  scarcely  moving,  fluid  exudate  is 
absorbed,  tension  is  lessened,  the  lymph-spaces  and  vessels 
distend,  and  lymphatic  absorption  becomes  active.  The 
application  of  heat  increases  the  ameboid  activity  of  the  leuko- 
cytes, phagocytes  gather  in  great  numbers  and  surround  an 
area  of  infection,  and  those  which  have  taken  up  bacteria 
or  tissue-debris  hurry  away.^  Heat  notably  lessens  the  pain 
of  inflammation.     It  is  often  used  purely  to  relieve  pain. 

T\\&  fonns  of  heat  are — (i)  fomentations;  (2)  poultices; 
(3)  water-bath  ;  and  (4)  dry  heat. 

Fouientation  is  the  application  to  the  skin  of  a  piece  of  flan- 
nel containing  a  hot  liquid.  A  basin  is  warmed  and  over  the 
top  of  the  basin  a  towel  is  placed.  A  piece  of  flannel  folded 
in  two  or  three  thicknesses  is  laid  upon  the  towel  and 
boiling  water  is  poured  upon  it.  By  twisting  the  towel  the 
water  is  squeezed  out.  Great  care  must  be  taken  to  squeeze 
the  water  out  of  the  flannel,  otherwise  the  skin  may  be 
scalded.  The  hot  flannel  is  laid  upon  the  desired  part.  A 
rubber-dam  larger  than  the  flannel  is  placed  over  it,  a  mass 
of  cotton  is  laid  upon  the  rubber-dam,  and  a  bandage  is  ap- 
plied. The  fomentation  must  be  changed  within  an  hour 
unless  a  hot-water  bag  has  been  placed  outside  of  the 
bandage,  in  which  case  it  need  not  be  changed  for  two  hours 
or  more.  The  flannel  which  is  dipped  into  the  hot  liquid  is 
known  as  a  "  stupe."  The  turpentine  stupe  is  made  by 
wringing  out  the  flannel  as  above  and  then  putting  upon  it 
from  10  to  20  drops  of  turpentine.  Instead  of  fomenting  the 
part,  steam  may  be  thrown  upon  it.  Fomentations  are  used 
chiefly  for  their  reflex  influence  over  deep  congestions  or  in- 
flammations. The  liquid  of  a  fomentation  may,  if  desired, 
contain  corrosive  sublimate,  carbolic  acid,  or  other  agents. 
A  fomentation  containing  an  antiseptic  is  known  as  an  anti- 
septic fomentation.  An  antiseptic  fomentation  or,  as  it  is 
often  called,  an  antiseptic  poultice,  is  made  and  applied  as 
follows  :  Gauze  is  used  instead  of  flannel,  and  is  laid  upon 
the  towel  over  the  basin  as  previously  described.  A  very 
warm  solution  of  corrosive  sublimate  (i  :  1000)  is  poured 
upon  the  gauze,  the  material  is  partly  wrung  out,  placed  upon 
the  part,  covered  with  a  rubber-dam,  and  upon  it  a  hot-water 
bag  is  placed.  Fomentations  are  very  useful  in  relieving 
pain  in  any  stage  of  an  inflammation  and  act  also  as  coun- 
terirritants.  Fomentations  are  used  in  preference  to  poul- 
tices   if  there    is    any    probability    of  a    surgical    operation 

^  Nancrede,  in  Principles  of  Surgery. 


92  INFLAMMA  TION. 

becoming  necessary,  because  skin  to  which  a  poultice  has 
been  applied  cannot  be  satisfactorily  sterilized. 

Poultice  or  Cataplasvi. — A  poultice  is  a  soft  mass  applied 
to  a  part  to  bring  heat  and  moisture  to  bear  upon  it.  Poul- 
tices can  be  made  of  ground  flaxseed,  of  slippery-elm  bark, 
of  arrowroot,  starch,  bread  and  milk,  potatoes,  turnips,  etc. 
To  make  a  flaxseed  poultice,  scald  a  spoon  and  a  tin  basin, 
put  the  flaxseed  into  the  dry  hot  basin,  and  pour  upon  it 
boiling  water  in  sufficient  quantity  to  form  a  thick  paste. 
The  proper  consistence  is  found  when  the  mass  would  stick 
if  it  were  thrown  against  a  wall.  It  is  now  spread  to  the 
thickness  of  a  quarter  of  an  inch  upon  a  piece  of  warm 
muslin,  a  free  edge  being  left  all  around,  the  edges  of  the 
muslin  are  turned  in,  and  the  flaxseed  is  covered  with  a  bit 
of  gauze  to  prevent  adhesion  to  the  skin.  The  poultice 
should  be  placed  upon  the  part  and  be  covered  outside  with 
oiled  silk,  a  rubber-dam,  or  waxed  paper.  A  mass  of  cotton 
is  applied  outside  of  the  rubber  and  the  poultice  is  held  in 
place  by  a  bandage  or  binder.  It  can  be  kept  very  warm 
for  a  considerable  period  by  placing  upon  it  a  bag  filled  with 
hot  water.  If  the  hot-water  bag  is  not  employed,  a  poultice 
should  be  changed  every  two  hours.  Spongiopilin,  when 
moistened  with  hot  water,  is  a  good  substitute  poultice. 
Lint  soaked  with  hot  water  and  covered  with  some  im- 
permeable material  does  very  well.  The  fermented  poultice, 
which  was  once  popular  for  gangrenous  ulcers,  was  made 
by  sprinkling  yeast  upon  an  ordinary  cataplasm.  The  char- 
coal poultice  is  made  by  stirring  charcoal  into  the  usual 
poultice-mass.  A  poultice  containing  opium  is  known  as  a 
"  sedative  "  poultice.  About  gr.  ij  of  opium  to  the  ounce  of 
poultice-mass  relieves  pain.  An  antiseptic  poultice  is  made 
by  partly  wringing  out  gauze  in  a  hot  solution  of  corrosive 
sublimate  (i  :  looo),  covering  it  with  oiled  silk,  and  placing 
a  hot-water  bag  upon  it  to  maintain  the  heat.  The  antisep- 
tic poultice  or  fomentation  is  of  great  sei-vice  in  removing 
sloughs  from  foul  wounds  and  ulcers.  It  is  the  only  form 
of  poultice  which  is  admissible  when  the  skin  is  broken. 
Poultices  must  not  be  kept  on  too  long,  as  they  will  cause 
vesication,  especially  in  adynamic  conditions.  If  a  poultice 
is  causing  vesication,  remove  it  or  sprinkle  it  with  pow- 
dered oxid  of  zinc.  If  suppuration  exists  or  is  seriously 
threatened,  do  not  waste  time  by  using  poultices,  but  incise 
at  once.  If  suppuration  is  seriously  threatened,  incision  may 
prevent  it  by  relieving  tension,  affording  drainage,  and  per- 
mitting of  the  local  use  of  antiseptics.     If  pus  exists,  it  can- 


TREATMENT.  93 

not  be  evacuated  too  soon.  To  use  poultices  and  delay  in- 
cision is  often  productive  of  irreparable  harm.  After  incision 
of  a  purulent  focus  it  is  often  useful  to  apply  an  antiseptic 
fomentation.  If  it  seems  probable  that  an  operation  will  become 
necessary  on  an  area  of  inflammation,  we  can  use  an  anti- 
septic fomentation,  but  never  an  ordinary  poultice.  The  ordi- 
nary poultice  is  a  vegetable  material  which  adheres  to  the 
skin,  enters  the  mouths  of  glands  and  follicles,  and  under- 
goes decay.  It  is  impossible  to  cleanse  a  part  thoroughly 
immediately  after  it  has  been  poulticed  with  flaxseed. 

Watcr-batJi. — The  continuous  hot  bath  is  now  rarely  em- 
ployed except  in  burns  and  cases  of  phagedena,  when  it  often 
proves  curative.  In  these  cases  an  antiseptic  agent  may  be 
dissolved  in  the  water.  Continuous  immersion  in  a  w^arm 
bath  is  regarded  favorably  by  some  surgeons  for  the  treat- 
ment of  slouging  wounds  and  large  purulent  areas.  The 
immersion  of  a  part  from  time  to  time  in  water  as  hot  as  can 
be  tolerated  is  useful  in  fully  developed  and  in  chronic  inflam- 
mation. Such  immersion  benefits  an  inflamed  joint,  lessen- 
ing the  pain,  swelling,  and  stiffness. 

Dry  heat  is  appHed  by  a  metallic  object  dipped  in  hot 
water  and  laid  upon  the  part ;  by  Leiter's  tubes,  through 
which  hot  water  flows  ;  b}'  the  hot-water  bag  or  by  the  hot- 
air  apparatus.  Some  surgeons  use  the  hot-water  bag  in  cases 
of  mild  appendicitis,  in  order  to  favor  the  formation  of  adhe- 
sions. The  hot-water  bag  is  often  soothing  and  beneficial 
when  laid  upon  an  inflamed  joint,  or  on  the  perineum  or  the 
hypogastric  region  in  cystitis.  A  bag  of  hot  sand,  a  hot 
brick,  or  a  bottle  or  can  of  hot  water  can  be  used  instead  of 
the  bag.  The  hot-air  apparatus  is  of  very  great  service  in 
the  treatment  of  inflamed  joints. 

Treatment  when  Suppuration  is  Threatened. — When  sup- 
puration is  threatened,  ordinary  hot  fomentations  or  anti- 
septic fomentations  must  be  used,  and  the  part  must  be  kept 
at  rest.  As  previously  explained,  the  flaxseed  poultice  is 
inadmissible.  When  suppuration  is  threatened  the  use  of 
heat  causes  the  collection  of  multitudes  of  leukocytes,  which 
tend  to  limit  the  area  of  infection  and  destroy  bacteria.  Even 
when  suppuration  is  not  prevented  heat  aids  in  the  rapid 
breaking  down  of  the  tissue  at  the  focus  of  the  inflammation 
and  causes  hordes  of  leukocytes  to  gather  and  encompass 
the  suppurating  tissue,  and  these  leukocytes  prevent  the 
spread  of  the  infection. 

In  most  cases,  when  suppuration  is  obviously  inevitable  or 
seriously  threatened,  a  free  incision  will  be  of  greatest  benefit. 


94  INFLAAIMATION. 

Irritants  and  Conntcrirritants  in  Inflammation. — Irritants 
attract  an  increased  supply  of  blood  to  the  part  whereon 
they  are  applied,  and  are  used  for  their  local  effects. 
Conntcrirritants  are  used  to  affect  by  reflex  influence  some 
distant  part.  In  chronic  inflammation  irritants  may  do  good 
by  promoting  the  blood-supply,  thus  favoring  the  removal 
of  exudates  (liniment  in  rheumatism  and  synovitis,  and 
nitrate  of  silver  in  ulcers).  Counterirritants  are  powerful 
pain-relievers  when  used  over  an  inflamed  structure  ;  they 
bring  blood  to  the  surface  and  are  thought  by  many  writers 
to  cause  anemia  of  internal  parts,  the  site  and  area  of  anemia 
depending  on  the  site,  the  area,  and  the  duration  of  the  sur- 
face-irritation. Nancrede  dissents  from  the  statement  that 
counterirritants  cause  anemia  of  internal  parts  ;  and  he  main- 
tains that  they  irritate  deeper  parts  and  cause  more  external 
blood  to  be  taken  to  them.  He  claims  that  a  blister  applied 
to  the  chest  produces  a  hyperemic  area  in  the  pleura. 
Nancrede,  in  his  w^ork  upon  the  Principles  of  Snrgcry,  refers 
to  Furneaux  Jordan's  opinion  that  direct  irritation  to  the  sur- 
face over  a  joint  adds  to  synovial  hyperemia,  and  that  con- 
sequently in  joint-inflammation  counterirritants  should  be 
applied  above  and  below  a  joint,  but  not  directly  over  it. 
As  a  matter  of  fact,  we  know  clinically  that  powerful 
counterirritation  directly  over  an  inflamed  superficial  joint 
is  occasionally  followed  by  an  aggravation  of  the  trouble, 
and  that  in  pericarditis  blistering  directly  over  the  pericar- 
dium may,  as  pointed  out  by  Brunton,  make  the  condition 
worse.  Counterirritants  not  only  relieve  pain  in  the  earlier 
stages  of  inflammation,  but  they  also  promote  absorption  of 
exudate  in  the  later  stages,  and  are  particularly  valuable  in 
chronic  inflammations.  Great  benefit  is  obtained  by  blister- 
ing old  thickened  ulcers,  and  by  painting  the  chest  with 
iodin  to  relieve  pleuritic  effusion.  Frictions,  besides  their 
pressure-effects,  act  as  counterirritants.  Frictions  may  re- 
lieve skin-pain,  and  are  associated  with  the  application  of 
stimulating  liniments  in  the  treatment  of  stiff  joints.  A 
mustard  plaster  is  a  valuable  counterirritant  in  an  acute 
deeply-seated  inflammation.  Tincture  of  iodin  is  extensively 
used  in  chronic  inflammation. 

There  is  no  more  efficient  method  of  relieving  pleural 
effusion  than  by  the  application  of  a  succession  of  blisters. 
Blisters  are  also  used  in  the  treatment  of  inflamed  joints, 
pericarditis,  pneumonic  consolidation  of  the  lung,  acute  and 
chronic  rheumatism,  etc. ;  and  are  applied  back  of  the  ears 
or  at  the  nape  of  the  neck  in  congestive  coma  or  meningitis. 


TREA  TMEXT.  95 

A  blister  can  be  produced  in  a  {q.\\  minutes  by  soaking  a  bit 
of  lint  in  chloroform,  and  after  appl}-ing  it  to  the  surface, 
covering  it  with  oiled  silk,  and  then  with  a  watch-glass. 
Equal  parts  of  lard  and  ammonia  will  blister  in  five  minutes. 
It  is  easier  to  blister  with  cantharidal  collodion  or  blistering- 
paper.  Before  appK'ing  a  blister,  shave  the  part  if  it  be 
hairy ;  then  grease  the  plaster  with  olive  oil  and  apply  it. 
Blistering  plaster  is  left  in  place  six  hours  in  the  case  of  an 
adult,  but  only  two  hours  in  the  case  of  an  old  person  or  a 
child ;  the  plaster  is  then  removed,  and  if  a  blister  has  not 
formed,  the  part  must  be  poulticed  for  a  feAv  hours.  When 
a  blister  is  obtained,  open  it  with  a  needle  which  has  been 
dipped  in  boiling  water.  If  the  surgeon  wishes  the  blister 
to  heal,  it  should  be  covered  with  a  piece  of  lint  smeared 
with  cosmolin  or  with  zinc  ointment.  If  it  is  to  be  kept 
open  for  a  time,  cut  awa}'  the  stratum  corneum  and  dress 
with  cosmolin,  each  ounce  of  which  contains  six  drops  of 
nitric  acid. 

Pustulation  can  be  effected  with  tartar-emetic  ointment 
or  with  Vienna  paste.  Tartar-emetic  ointment  was  formerly 
used  on  the  scalp  in  meningitis.  Vienna  paste  consists  of  5 
parts  of  caustic  potash  and  6  parts  of  lime  made  into  a  paste 
with  alcohol.  It  is  applied  for  five  minutes,  and  is  then 
washed  off  with  vinegar. 

The  hot  iron  is  the  most  powerful  of  counterirritants.  It 
is  chiefly  used  in  chronic  inflammation  of  joints,  bone,  and  the 
spinal  cord.  The  application  is,  of  course,  \'er}"  painful,  and 
it  is  best  to  give  an  anesthetic  before  using  the  cauter}'.  A 
flat  cautery  iron  may  be  used,  or  the  round  iron.  The  latter 
is  known  as  the  button  or  Corrigan's  cautery.  The  iron  is 
used  at  a  white  heat.  One  area  or  several  may  be  seared. 
The  cautery  is  drawn  lightly  two  or  three  times  o\"er  each 
spot  we  wish  to  burn.  The  object  is  to  destroy  onh*  the 
superficial  layers  of  the  skin.  After  the  cauterization  is  com- 
pleted, lint  wet  wath  iced  water  is  applied  for  several  hours  to 
alia}'  pain,  and  then  hot  antiseptic  fomentations  are  used 
until  the  slough  separates. 

If  we  wish  to  prevent  healing  after  separation  of  the 
slough,  dress  the  sore  with  cosmolin,  each  ounce  of  which 
contains  6  drops  of  nitric  acid.  It  is  not  wise  to  cauterize 
deeph'  directly  over  a  superficial  joint. 

Constitutional  Treatment  of  Inflammation. — Certain 
remedies  are  used  in  inflammation  for  their  general  or  con- 
stitutional effects  ;  these  remedies  are — (i)  general  bleeding; 
(2)  arterial  sedatives;  (3)  cathartics;  (4)  diaphoretics;  (5)  di- 


96  INFLAMMA  TION. 

uretics  ;  (6)  anodynes ;  (7)  antipyretics  ;  (8)  emetics  ;  (9)  mer- 
cury and  iodids  ;  (lo)  stimulants  ;  and  (l  l)  tonics. 

General  bleeding,  venesection,  or  pJilebotoniy,  is  suited  to  the 
early  stages  of  an  acute  inflammation  in  a  young  and  robust 
subject.  The  indication  for  its  employment  is  increased  arte- 
rial tension,  as  shown  by  a  strong,  full,  rapid,  and  incom- 
pressible pulse  in  a  vigorous  young  patient.  General  blood- 
letting diminishes  blood-pressure  and  increases  the  speed  of 
the  blood-current,  thus  amends  stasis,  absorbs  exudate,  and 
washes  adherent  corpuscles  from  the  vessel-wall ;  further- 
more, it  reduces  the  whole  amount  of  body-blood  and  thus 
forces  a  greater  rapidity  of  circulation,  decreases  the  amount 
of  fibrin  and  albumin,  lowers  the  temperature,  arrests  cell- 
proliferation,  and  stops  effusion. 

This  procedure  was  in  former  days  so  highly  esteemed 
that  it  settled  into  a  routine  formula  to  be  applied  to  every 
condition  from  yellow  fever  to  dislocation.  The  terrible 
mortality  of  the  cholera  epidemics  from  1830  to  1835  led 
practitioners  to  question  the  belief  that  bleeding  was  a 
general  panacea,  and  from  this  doubt  there  was  born  in  the 
next  generation  violent  opposition  to  bloodletting  in  any 
disease.  Like  most  reactions,  opposition  has  gone  too  far, 
the  pendulum  of  condemnation  has  swung  beyond  the  line 
of  truth  and  sense,  and  thus  is  universally  neglected  or 
broadly  condemned  a  powerful  and  valuable  resource.  Many 
physicians  of  long  experience  have  never  seen  a  person 
bled ;  its  performance  is  not  demonstrated  in  most  schools, 
and  but  few  patients  and  families  will  permit  it  to  be  done. 
But  when  properly  used  it  is  occasionally  beneficial.  It  is 
only  applicable,  however,  to  the  young,  strong,  and  robust, 
and  not  to  the  old,  weak,  or  feeble.  It  is  used  for  violent 
acute  inflammations  of  important  organs  or  tissues,  and  not 
for  low  inflammations  or  for  slight  affections  of  unimportant 
parts.  It  is  used  in  the  early,  but  not  in  the  late,  stages  of 
an  inflammation.  It  is  used  when  the  pulse  is  frequent,  full, 
hard,  and  incompressible,  but  not  when  it  is  slow,  small, 
soft,  compressible,  and  irregular.  It  is  used  when  the  face 
is  flushed,  but  not  when  it  is  pallid.  It  is  not  used  in  fat 
persons,  drunkards,  very  nervous  people,  or  the  sufferers 
from  adynamic,  septic,  or  epidemic  diseases.  It  is  of  value 
in  some  few  cases  of  congestion  of  the  lungs,  pneumonitis, 
pleuritis,  meningitis,  prostatitis,  cystitis,  and  other  acute  in- 
flammatory conditions.     (See  Phlebotomy.) 

After  bleeding,  the  patient  should  be  put  upon  arterial 
sedatives,  diuretics,  diaphoretics,  anodynes,  and,  if  necessary. 


TREA  TMEXT.  97 

purgatix'cs.  A  favorite  mixture  of  Prof.  S.  D.  Gross  was  the 
antinionial  and  saline,  consisting  of  gr.  xl  of  Epsom  salt, 
gr.  -^-^  of  tartar  emetic,  2  drops  of  tincture  of  aconite,  and  3j 
of  sweet  spirits  of  niter,  in  enough  ginger  syrup  and  water 
to  make  sss ;  given  every  four  hours. 

Arterial  sedatives  are  of  great  use  before  stasis  is  pro- 
nounced ;  but  if  used  after  stasis  is  established  they  will 
increase  it.  If  stasis  exists  it  may  be  relieved  by  blood- 
letting, local  or  general,  and  then  arterial  sedatives  can  be 
given.  Either  local  bleeding  or  venesection  abolishes  stasis 
and  lowers  tension,  and  arterial  sedatives  maintain  the  effect 
and  hold  the  ground  which  is  gained.  The  arterial  sedatives 
employed  are  aconite,  veratum  viride,  gelsemium,  and  tartar 
emetic.  These  sedatives  lessen  the  force  and  the  frequency 
of  the  heart-beats,  and  thus  slow  and  soften  the  pulse,  and 
are  suited  to  a  robust  person  with  an  acute  inflammation,  but 
are  not  suited  to  a  weak  individual  in  an  adynamic  state. 

Aconite  is  given  in  small  doses,  never  in  large  amounts. 
One  drop  of  the  tincture  in  a  little  water  is  given  every  half 
hour  until  its  effect  is  manifest  on  the  pulse,  when  it  may  be 
given  ever}"  two  or  three  hours.  Large  doses  of  aconite 
produce  pronounced  depression,  and  are  dangerous.  Aco- 
nite lowers  the  temperature,  slows  the  pulse,  and  produces 
diaphoresis. 

Veratrinn  viride  is  a  powerful  agent  to  slow  the  pulse  and 
to  lower  blood-pressure ;  it  produces  moisture  of  the  skin, 
and  often  nausea.  It  is  given  in  i-drop  doses  of  the  tinct- 
ure every  half  hour  until  its  physiological  effects  are  mani- 
fested, when  the  period  between  doses  is  extended  to  two 
or  three  hours.  Ten  drops  of  laudanum  given  a  quarter 
of  an  hour  before  each  dose  of  veratrum  viride  will  prevent 
nausea. 

Gclseiniuin  is  an  arterial  sedative  highly  appro\-ed  by 
Bartholow.  It  is  given  in  doses  of  5  to  10  drops  of  the 
tincture  every  three  or  four  hours. 

Tartar  emetic  lowers  arterial  tension  and  lessens  the  pulse- 
rate.  This  drug  is  not  largely  employed ;  if  it  is  used  with 
the  greatest  care,  it  is  no  better  than  some  other  agents,  and 
if  it  is  not  so  used  it  will  cause  dangerous  depression.  The 
dose  is  from  gr.  -^  to  gr.  -^  in  water  every  three  hours  until 
the  physiological  effects  are  manifest. 

Cathartics. — Purgation  is  of  great  value  in  inflammation. 
By  it  putrid  material  is  removed  from  the  intestine,  fluid  con- 
taining poisonous  elements  is  drawn  from  the  blood,  and  the 
liability  to  infection  of  the  tissues  is  lessened.  The  administra- 
7 


98  INFLAMMA  TION. 

tion  of  purgatives  is,  of  course,  not  to  be  a  routine  procedure 
in  inflammatory  states.  The  bowels  may  be  acting  so  freely 
that  no  cathartic  is  required.  Treatment  in  an  inflammation 
should  be  inaugurated,  if  constipation  exists,  by  giving  a  cath- 
artic. The  tongue  affords  important  indications  as  to  the  neces- 
sity for  purgation.  Castor  oil  can  be  given  in  capsules,  or  the 
juice  of  half  a  lemon  is  squeezed  into  a  tumbler,  i  ounce  of 
oil  poured  in,  and  the  rest  of  the  lemon  is  squeezed  on  top, 
thus  making  a  not  unpalatable  mixture.  Aloin,  podophyl- 
lum, the  salines,  and  calomel  in  5-  or  lo-grain  doses,  followed 
by  a  saline,  have  their  advocates.  In  peritonitis  the  salines 
are  of  unquestionable  value,  a  teaspoonful  of  Epsom  salt  and  a 
teaspoonful  of  Rochelle  salt  being  given  hourly  until  a  move- 
ment occurs.  In  the  course  of  inflammation,  from  time  to  time, 
if  there  be  constipation,  a  coated  tongue,  and  foulness  of  the 
breath,  there  should  be  ordered  gr.  j  of  calomel  with  gr. 
xxiv  of  bicarbonate  of  sodium,  made  into  twelve  povv'ders, 
one  being  given  every  hour ;  if  the  bowels  are  not  moved  by 
the  time  the  powders  are  all  taken,  a  saline  should  be  given. 
If  a  violent  purgative  effect  is  desired,  as  in  meningitis,  croton 
oil  or-elaterium  may  be  ordered.  If  constipation  is  persistent, 
give  fluid  extract  of  cascara  sagrada  daily  (20  to  40  drops), 
or  a  pill  at  night  containing  gr.  \  of  extract  of  belladonna, 
gr.  \  of  extract  of  nux  vomica,  gr.  y^Q-  of  aloin,  gr.  \  of 
extract  of  physostigma,  and  gt.  \  of  oil  of  cajuput.  Enemas 
or  clysters  may  be  used  in  some  cases.  A  very  useful 
enema  is  composed  of  fsj  of  oil  of  turpentine,  f,5iss  of  olive 
oil,  f^ss  of  mucilage  of  acacia,  in  fsx  of  water.  Soapsuds 
and  vinegar  in  equal  parts  make  a  serviceable  clyster.  A 
combination  of  oil  of  turpentine,  castor  oil,  the  yolk  of  an 
Q.^%,  and  water  can  be  used.  Asafetida,  gr.  xxx  to  the  yolk 
of  one  &^2^,  makes  a  good  enema  to  amend  flatulence. 

Diaphoretics  are  very  useful.  A  profuse  sweat  removes 
much  toxic  material  from  the  blood  and  in  the  beginning  of  an 
acute  inflammation,  such  as  tonsillitis,  may  abort  the  disease. 
Dover's  powder  is  commonly  used,  but  pilocarpin  is  preferred 
by  some.  Camphor  in  doses  of  from  5  to  10  grains  is  dia- 
phoretic, and  so  are  antimony  and  ipecac.  Acetate  and 
citrate  of  ammonium,  opium,  alcohol,  hot  drinks,  heat  to  the 
surface  (baths,  hot  bricks,  hot-water  bags),  serpentaria,  and 
guaiac  are  diaphoretic  agents. 

Diuretics  are  useful  in  fevers  when  the  urine  is  scanty  and 
high-colored,  and  are  valuable  aids  in  removing  serous  effu- 
sions and  other  exudates.  Among  the  diuretics  may  be  men- 
tioned   calomel    in    repeated    large    doses,    cocain,    caffein, 


TKKA  TMENT.  99 

alcohol,  digitalis,  the  nitrites,  squill,  turpentine,  copaiba,  and 
cantharides.  The  liquor  potassa;  and  the  acetate  of  potas- 
sium are  the  best  agents  to  increase  the  solids  in  the  urine. 
The  liquor  potassii  citratis  in  doses  of  fgj  to  f^iv  is  efficient. 
Large  draughts  of  water  wash  out  the  kidneys.  If  the  heart 
is  weak,  citrate  of  caffein  is  a  good  stimulant  diuretic. 

Anodynes  and  hypnotics  may  be  required.  Dover's  powder, 
besides  being  diaphoretic,  is  anodyne.  Opium  acts  well  after 
bleeding  or  purgation.  If  it  causes  nausea,  it  should  be  pre- 
ceded one  hour  by  the  administration  of  gr.  xxx  of  bromid 
of  potassium.  Opium  is  used  by  the  mouth,  by  the  rectum, 
or  hypodermatically.  It  is  used  when  there  is  pain,  but  its 
use  is  not  to  be  long  persisted  in  if  it  can  be  avoided.  It  is 
given  in  doses  measured  purely  by  the  necessities  of  the 
case.  If  opium  disagrees,  try  the  combination  of  morphin 
with  atropin.  After  an  operation  antipyrin  or  phenacetin 
will  often  quiet  pain  and  secure  sleep.  When  a  person  feels 
"so  tired  he  can't  sleep,"  alcohol  in  the  form  of  wdiiskey  or 
brandy  must  be  given.  Sleeplessness  not  due  to  pain  is  met 
by  chloral,  trional,  the  bromids,  or  sulphonal.  Chloral  is 
dangerous  in  conditions  of  weak  heart  or  exhaustion.  Bro- 
mids must  be  given  in  large  doses  to  be  efficient.  Sulphonal 
must  be  given  about  four  or  five  hours  before  sleep  is  ex- 
pected, in  doses  of  from  gr.  x  to  gr.  xx  in  hot  milk  or  hot 
mint-water.  Trional  is  safe  and  very  satisfactory.  It  is  given 
in  doses  of  gr.  xv  to  gr.  xxv  in  hot  water. 

Antipyretics. — Diaphoretics,  purgatives,  and  arterial  seda- 
tives lower  temperature,  and  have  previously  been  alluded  to 
(p.  96).  There  are  two  great  classes  of  febrifuges — those 
which  lessen  heat-production  and  those  which  increase  heat- 
elimination.  In  the  first  group  we  find  quinin,  salicylic  acid 
and  the  salicylates,  kairin,  alcohol,  antimony,  aconite,  digitalis, 
cupping,  and  bleeding.  In  the  second  group  we  find  alcohol, 
nitrous  ether,  antipyrin,  acetanilid,  phenacetin,  opium,  ipecac, 
cold  to  the  surface,  and  cold  drinks.  In  surgical  inflammations 
it  is  rarely  necessary  to  employ  heroic  means  to  lower  tem- 
perature. The  use  of  such  an  agent  as  antipyrin  is  contra- 
indicated  in  the  weak  and  adynamic,  and  it  is  never  to  be 
thought  of  as  a  means  of  lowering  temperature  unless  the 
latter  goes  above  103°  F.  Quinin,  in  doses  of  gr.  xx  to  gr. 
xxx  given  at  4  p.  m.,  may  prevent  an  evening  rise ;  salol  or 
salicin  can  be  given  during  the  day.  Inunctions  of  30 
minims  of  guaiacol  lower  the  temperature  in  tubercular  con- 
ditions and  in  septic  fevers.  These  inunctions  are  made 
upon   the   abdomen,   and   often   produce  surprising   results. 


lOO  INFLAMMATION. 

Dujardin-Beaunietz  maintained  that  fever  is  a  condition  in 
which  the  organism  is  endeavoring  to  oxidize  and  render 
inert  certain  poisonous  material,  and  that  antipyretic  drugs 
lessen  oxidation  and  actually  make  the  patient  worse.  This 
view  is  in  accordance  with  the  experience  of  a  number  of 
surgeons.  It  is  a  suggestive  fact  that  bacteria  are  said  to 
multiply  more  rapidly  when  kept  at  about  the  normal  body 
temperature  than  when  kept  at  fever  heat  (102°  F.,  or  more). 
The  mere  discomfort  of  fever  may  be  much  mitigated  by 
antipyretic  drugs,  but  the  fever-process  is  not  benefited  by 
them. 

Emetics. — Emetics  may  do  good  when  the  patient  suffers 
from  a  parched,  coated  tongue,  a  dry  and  hot  skin,  nausea, 
and  gastric  oppression,  but  it  is  very  rarely  in  these  days 
that  we  employ  them.  There  can  be  used  ."j  of  alum  in 
molasses,  gr.  xx  of  sulphate  of  zinc,  or  a  tablespoonful  of 
mustard  and  a  teaspoonful  of  salt  given  in  warm  water  and 
followed  by  large  draughts  of  warm  water.  Ipecac  in  a  dose 
of  gr.  XX  can  be  employed.  The  emetic  dose  of  tartar  emetic 
is  gr.  ij,  but  it  is  too  depressant  a  drug  to  trifle  with.  The  sul- 
phuret  of  antimony  in  doses  of  from  i  to  5  grains  is  safe. 
Apomorphin  hypodermatically,  in  a  dose  of  from  gr.  ylg-  to  gr. 
1,  will  act  in  five  minutes.  Emetics  are  valuable  in  inflamma- 
tory conditions  of  the  air-passages,  but  their  use  is  contra- 
indicated  in  diseases  of  the  heart,  brain,  and  bowels,  in  hernia, 
in  dislocations,  in  fractures,  and  in  aneurysms. 

Mcrairy  and  the  lodids. — Mercury  is  an  alterative — that 
is,  an  agent  which  favorably  affects  body-nutrition  without 
causing  any  recognizable  change  in  the  fluids  or  the  solids 
of  the  body.  Mercury  lessens  blood-plasticity,  hinders  the 
exudation  of  liquor  sanguinis — thus  furnishing  less  food  to 
the  cells  in  the  perivascular  tissues — and  retards  cell-pro- 
liferation. Further,  by  a  stimulant  action  on  the  absorbents 
it  promotes  the  breaking  up  of  an  existing  inflammatory 
exudation,  and  hence  limits  damage  from  excess  of  new  for- 
mation. The  time  at  which  mercury  is  best  given  is  when 
violent  symptoms  have  abated,  the  guides  being  a  reduced 
temperature  and  a  moist  skin.  Mercury  is  often  given  in 
conjunction  with  the  local  use  of  sorbefacients  (ichthyol,  or 
mercurial  ointment,  when  possible,  is  associated  with  com- 
pression of  the  inflamed  part.)  It  is  sometimes  given  until 
the  gums  are  slightly  touched,  but  it  is  not  given  to  the  point 
of  salivation.  When  the  breath  becomes  offensive  and  the 
gums  tender  on  snapping  the  teeth,  or  when  griping  and 
diarrhea  begin,  the   dose   should   be   reduced,  or  the   drug 


TREATMEXT.  lOI 

should  be  stopped  (see  PtyalismV  In  iritis  mercury  is  used 
to  get  rid  of  the  plastic  effusion  which  is  causing  pupillary 
fixation  and  opacity.  In  keratitis  the  gums  should  be  touched 
lightly.  In  orchitis,  after  the  subsidence  of  the  acute  symp- 
toms, mercur}'  should  be  employed.  In  pericarditis,  menin- 
gitis, and  in  many  chronic  and  lingering,  and  in  all  syphilitic 
inflammations,  this  drug  can  be  used. 

Some  persons  will  be  salivated  with  very  minute  doses  of 
mercury,  either  because  of  idiosyncrasy  or  previous  satura- 
tion. Others  can  take  enormous  doses  without  any  appre- 
ciable constitutional  effect.  The  action  of  mercurials  can  be 
favored  by  a  combination  with  ipecac  or  with  tartar  emetic. 

In  giving  mercury,  if  a  prompt  effect  is  desired,  give  gr.  iij 
of  calomel  every  three  hours  until  a  metallic  taste  is  noted 
in  the  mouth.  If  the  case  is  not  so  urgent,  gray  powder  is 
a  good  combination.  Children  are  given  calomel  and  sugar 
or  mercury  and  chalk.  If  it  is  desired  to  give  the  drug  for 
some  time,  corrosive  sublimate  is  a  suitable  form,  and  small 
doses  will  actually  increase  the  number  of  red  blood-cor- 
puscles. Corrosive  sublimate  is  to  be  given  alone  or  com- 
bined only  with  iodid  of  potassium.  The  green  iodid  of 
mercury  is  a  drug  suitable  for  prolonged  administration.  In 
the  prolonged  use  of  mercury  it  will  often  be  necessary  to 
give  at  the  same  time  a  little  opium  to  prevent  diarrhea  and 
griping.  A  rapid  effect  can  be  obtained  by  rubbing  daily 
with  a  gloved  hand  oj  of  the  oleate  of  mercury  or  oSS  of 
the  ointment  into  the  groins,  the  axillae,  or  the  inside  of  the 
thighs.  Suppositories  of  mercurial  ointment  induce  rapid 
ptyalism.  Hypodermatic  injections  of  corrosive  sublimate 
or  gray  oil  may  be  used,  and  must  be  thrown  deeply  into 
the  muscles  of  the  buttock  or  back.  Old  people,  those 
who  are  exhausted,  anemic,  and  broken  down,  and  the 
tubercular  bear  mercury  badly.  If  it  be  given  to  them  at 
all,  it  must  only  be  in  small  amounts  and  for  a  brief  time. 

Alkaline  iodids  are  useful  in  removing  the  products  of 
inflammation  ;  they  can  be  given  for  a  long  time,  and  admir- 
ably supplement  mercurials.  Iodid  of  potassium  can  be  pre- 
scribed in  combination  with  corrosive  sublimate  as  follows : 

5c.   Hydrarg.  chlor.  corros.,  gr.  ij  ; 

Potass,  iodidi,  ^v  et  ^j  ; 

Syr.  sarsaparillse  comp.,  q.  s.  ad  f  5viij. — M. 
Sig.  f^ij,  in  water,  after  meals. 

Iodid  of  potassium,  well  diluted,  is  given  on  a  full  stom- 
ach ;  it  is  never    given  concentrated    or    before    meals.     A 


1 02  I  NFL  A  MMA  TION. 

convenient  mode  of  administration  is  to  procure  a  concen- 
trated solution  of  the  iodid  of  potassium,  remembering  that 
every  drop  equals  gr.  j  of  the  drug,  and  give  as  many 
drops  as  may  be  desired  in  half  a  glass  of  water  after  meals. 
If  the  medicine  disagrees,  add  to  each  dose,  after  it  is  put  in 
water,  3j  of  the  aromatic  spirit  of  ammonia.  Extract  of  lic- 
orice is  a  good  vehicle  for  the  iodid.  If  the  mixture  in  water 
disagrees,  the  drug  should  be  given  in  milk.  Capsules  are 
satisfactory,  but  a  drink  of  water  should  be  taken  just  before 
and  again  just  after  taking  a  capsule,  to  protect  the  stomach 
from  the  concentrated  drug.  Iodid  of  sodium  may  agree 
when  iodid  of  potassium  does  not.  When  the  iodids  dis- 
agree they  produce  iodism.  The  first  indications  of  iodism 
are  a  bad  taste  in  the  mouth,  running  of  the  eyes  and  nose, 
and  sneezing,  followed  by  a  feeling  of  exhaustion,  absolute 
loss  of  appetite,  nausea,  tremor,  and  skin-eruptions  (acne, 
hemorrhages,  blebs,  hydroa,  etc).  If  iodism  occurs,  stop 
the  drug  and  give  the  patient  Fowler's  solution  in  increas- 
ing doses,  laxatives,  diuretic  waters,  and  also  nutritious  food, 
and  stimulants  if  depression  is  great.  Sometimes  belladonna 
does  good  in  obstinate  cutaneous  disorders  induced  by  the 
iodids. 

Remedies  Directed  Against  Special  Morbid  States. — If  in- 
flammation is  associated  with  rheumatism,  gout,  scurvy, 
syphilis,  tuberculosis,  or  any  other  constitutional  disease  or 
predisposition,  appropriate  treatment  should  be  instituted  to 
control  the  disease  or  combat  the  predisposition,  and  at  the 
same  time  the  area  of  inflammation  must  be  locally  treated. 
Syphilis  is  treated  by  the  internal  use  of  mercury,  and  in 
some  cases  the  iodids  are  also  given ;  scurvy,  by  vegetable 
juices  and  potash  salts;  rheumatism,  by  the  alkalies  or  sali- 
cylates ;  gout,  by  colchicum  or  piperazin  ;  tuberculosis,  by 
the  fats,  tonics,  and  an  open-air  life. 

The  use  of  alcoholic  stimidants  is  called  for  by  conditions 
rather  than  by  diseases,  being  indicated  by  the  state  of 
the  patient  rather  than  by  the  name  of  the  malady.  For 
a  brief  acute  inflammation  in  a  robust  young  person  alcohol 
is  not  needed ;  but  all  who  are  weak  or  exhausted,  be  they 
young  or  old,  all  who  are  aged,  those  who  are  accustomed 
to  alcoholic  beverages,  those  who  have  high  temperatures  or 
failure  of  circulation,  and  those  who  labor  under  septic  in- 
flammations or  adynamic  processes — require  alcohol,  and  it 
should  be  given  with  a  free  hand.  In  an  acute  malady,  a  feeble, 
compressible,  rapid,  or  irregular  pulse,  and  great  weakness 
of  the  first  sound  of  the  heart  are  indications  that  alcohol  is 


TREATMENT.  IO3 

required.  Low,  muttering  delirium  is  a  strong  indication  for 
stimulation.  There  is  no  dose  of  alcohol  for  these  states;  it  is 
given  for  its  effect.  Two  ounces  of  brandy  or  whiskey  may 
be  needed  in  a  day,  or  perhaps  twenty  ounces.  If  the  breath 
of  the  patient  smells  strongly  of  the  alcohol,  he  is  getting 
too  much.  If  delirium  increases  after  each  dose,  alcohol  is 
doing  harm.  Alcohol  is  contraindicated  in  acute  meningitis. 
In  acute  illness  use  whiskey,  brandy,  champagne,  or  alcohol 
and  water.  During  convalescence  there  may  be  used  a 
little  spirit,  port,  claret,  or  sherry  wine,  or  malt  liquor. 
These  agents  will  promote  appetite,  digestion,  and  sleep. 

Strychnin  is  a  very  valuable  stimulant.  It  can  be  given 
in  doses  of  gr.  -^-^  to  gr.  2V  three  times  a  day. 

Tonics  are  indicated  during  convalescence  from  acute  and 
throughout  the  course  of  chronic  inflammations.  There  may 
be  used  iron,  quinin,  and  strychnin  in  the  form  of  elixir; 
iron  alone,  as  in  the  tincture  of  the  chlorid  ;  quinin  in  tonic 
doses  (gr.  vj  to  gr.  viij  daily) ;  or  Fowler's  solution  of  arsenic. 
An  excellent  pill  consists  of — 

R.  Acid,  arsenos.,  gr- j ; 

Strychnin!,  gr.  ss ; 

Quinini,  gr.  xiviij  ; 

Ferri  redact.,  gr.  vj. — M. 
Ft.  in  pil.  No.  xxiv. 
Sig.  One  after  each  meal. 

Bitter  tonics  before  meals  improve  the  appetite.  One  of  the 
best  of  tonics  is  tincture  of  nux  vomica  in  gradually  increas- 
ing doses. 

Antiphlogistic  regimen  is  a  term  comprising  the  necessary 
directions  relating  to  diet,  ventilation,  cleanliness,  etc. 

Diet. — When,  in  the  early  stages  of  an  acute  inflammation, 
the  patient  cannot  eat,  there  must  be  administered  a  cathartic 
before  food  is  given.  Nausea  is  combated  with  calomel 
and  soda,  drop-doses  of  a  6  per  cent,  solution  of  cocain,  iced 
champagne,  iced  brandy,  chloroform-water,  hot  water,  cracked 
ice,  or  the  application  of  counterirritation  to  the  epigastric 
region.  When  the  process  is  depressive  from  the  start,  and 
in  any  case  after  the  earliest  stage,  feeding  is  of  vital  mo- 
ment. The  great  tissue-waste  calls  for  large  quantities  of 
nutritive  material,  but  the  impaired  digestion  demands  that 
the  food  shall  be  easily  assimilable;  hence  it  is  taken  in  liquid 
form,  small  quantities  being  frequently  given.  Milk  contains 
all  the  elements  required  by  the  body,  and  is  the  food  of  foods. 
If  it  disagrees,  it  should  be  boiled  and  mixed  with  lime-water, 
or  to  each  dose  an  equal  amount  of  Vichy  or  soda-water  may 


1 04  I  NFL  A  MMA  TION. 

be  added.  Peptonized  milk  is  a  valuable  agent.  One  part 
of  milk,  2  parts  of  cream,  and  2  parts  of  lime-water  make 
a  nutritious  and  digestible  mixture.  Milk  punch  is  largely- 
used.  Whey  may  be  used  when  plain  milk  cannot  be  taken. 
Eggs  are  highly  nutritious,  but  are  apt  to  disturb  the  stom- 
ach ;  they  may  be  given  as  egg-nog,  or  simply  soft-boiled, 
or  the  yolk  can  be  beaten  up  in  a  cup  of  tea.  When  con- 
siderable nausea  exists  the  yolk  of  an  o.^'g  may  be  added  to 
5j  of  lemon-juice  and  3ij  of  sugar,  the  glass  being  filled  with 
carbonated  water.  Beef  tea  is  certainly  a  stimulant,  but  its 
food-powers  are  questionable.  It  is  prepared  by  cutting  up 
one  pound  of  lean  beef,  adding  to  it  a  quart  of  water,  and 
then  simmering,  but  not  boiling,  down  to  a  pint,  finally  fil- 
tering and  skimming  the  liquid.  The  dose  is  a  wineglassful 
seasoned  to  taste.  Meat-juice,  obtained  by  squeezing  partly 
cooked  meat  with  a  lemon-squeezer,  is  extremely  nutritious. 
Liquid-beef  peptonoids  are  both  agreeable  and  nutritious ; 
they  are  given  in  doses  of  Iss  to  ^j.  Clam-juice  is  palatable 
and  digestible.  When  nothing  else  will  stay  on  the  stomach 
koumiss  will  often  be  retained.  This  fermented  milk  is 
nutritious,  stimulant,  and  very  useful.  Coffee  is  a  valuable 
stimulant  in  febrile  conditions.  If  the  stomach  retains  no 
food,  the  patient  must  be  fed  entirely  by  the  rectum.  If  the 
stomach  rejects  most  of  the  food  swallowed,  mouth-feeding 
must  be  supplemented  by  nutritive  rectal  enemata.  When 
the  sufferer  feels  able  to  eat  a  little,  any  good  soup,  strained 
and  skimmed,  should  be  ordered.  As  the  patient  gets 
better  he  may  be  fed  on  sweetbreads,  chops,  oysters,  etc., 
until  he  gradually  reaches  ordinary  diet. 

The  temperature  should  be  taken  at  regular  intervals,  and 
the  condition  of  the  gastro-intestinal  tract  should  be  observed. 
The  urine  must  be  examined  at  intervals,  and  the  daily 
amount  passed  must  be  known.  If  insufficient  urine  is  being 
passed,  increase  the  amount  of  fluid,  particularly  of  water, 
given  by  the  mouth.  If  the  urine  is  scanty  and  the  patient 
is  nauseated  by  drinking  water,  give  enemata  of  hot  saline 
fluid  or  employ  hypodermoch^sis.  The  pulse  and  lieart  must 
be  frequently  observed,  and  cardiac  weakness  must  be  com- 
bated by  suitable  stimulants. 

Ventilation  and  Cleanliness. — The  ventilation  of  the  apart- 
ment is  of  the  greatest  importance.  Every  day  the  windows 
should  be  opened  widely  for  a  time,  the  patient,  of  course, 
being  protected.  When  the  windows  are  open  the  air  of  a 
room  can  be  quickly  changed  by  swinging  the  door  to  and 
fro.     A  constant  access  of  fresh  air  must  be  secured,  and 


HEALIXG   BY  FIRST  INTENTION.  I05 

the  temperature  kept  as  near  as  possible  to  68°  F.  The  sick 
man  must  be  cleaned  and  be  sponged  off  with  alcohol  and 
water  every  day  if  high  fever  exists.  It  is  important  that  the 
bed-clothing  be  clean  and  that  the  sheet  be  unwrinkled,  as 
otherwise  bed-sores  may  form. 

IV.  REPAIR. 

When  a  tissue  is  damaged,  it  reacts  to  the  injur}-  and 
Nature  attempts  to  effect  repair.  It  is  held  by  many  that 
inflammation  is  a  destructive  process  and  repair  is  a  con- 
structive process ;  that  repair  is  constantly  effected  in  an 
aseptic  wound  without  many  of  the  evidences  of  inflamma- 
tion ;  that  repair  does  not  proceed  from  inflammation,  but  is 
retarded  or  prevented  if  inflammation  occurs.  As  before 
stated,  we  agree  Avith  Adami,  that  inflammation  is  reaction 
to  injury  and  the  effort  of  Nature  to  repair  the  injury.  As 
Adami  points  out,  the  attempt  to  repair  ma}'  fail,  the  reaction 
to  injury  being  excessive  or  not  powerful  enough  ;  but  even 
should  the  attempt  fail  the  conservative  intention  exists. 
"  What  is  the  development  of  cicatricial  tissue  but  an  attempt 
at  repair?  What  other  nieaning  can  be  ascribed  to  the  in- 
creased bactericidal  power  of  the  inflammator}*  exudate  as 
compared  with  that  of  ordinar}^  hmiph  and  blood-serum  ? 
Why  do  leukocytes  accumulate  in  a  region  of  injur}-  ?  Why 
do  some  of  them  incorporate  bacteria  and  irritant  particles, 
and  others  bring  about  the  destruction  of  these  without 
necessarily  ingesting  them  ?  All  these  are  means  whereby 
irritants  are  antagonized  or  removed,  and  reparation  and 
return  to  the  normal  sought  after."  ^ 

Healing  by  First  Intention. — A  A\ound  ma}-  heal  by 
"first  intention."  This  mode  of  healing,  wdiich  is  known 
as  "primary  union,"  occurs  without  suppuration,  and  is 
observed  in  the  healing  of  an  aseptic  wound.  If  infection 
occurs,  primar}'  union  will  not  take  place.  The  phrase  "  b}^ 
first  intention  "  comes  down  to  us  from  the  past.  It  was 
properl}'  thought  that  Nature  intends  to  repair  a  wound,  and 
first  intention  signifies  the  first  or  most  desirable  wa}'  to  be 
wished  for.  In  a  small  aseptic  incision,  in  which  no  con- 
siderable vessels  are  cut,  repair  will  take  place  very  rapidly 
after  the  edges  have  been  approximated  and  the  wound 
dressed.  In  fact,  the  wound-edges  ma}'  be  firmh'  held 
together  in  twenty-four  hours.  In  such  a  wound  a  small 
amount  of  blood    flows    from    the    capillaries    between  the 

^  Adami,  in  Allbutt's  System  of  Medicine. 


I06  REPAIR. 

edges  of  the  wound,  and  this  blood  clots.  A  trivial  amount 
of  exudation  and  some  few  migrated  corpuscles  pass  into  the 
clot  and  into  the  tissues.  The  fixed  connective-tissue  cells 
and  the  endothelial  cells  of  the  vessels  multiply,  and  form 
epithelioid  cells,  known  as  fibroblasts.  The  fibroblasts  multi- 
ply, so  that  the  new  cells  from  one  side  of  the  wound  finally 
interlace  with  the  new  cells  from  the  other  side.  These  fibro- 
blasts eat  up  many  of  the  leukocytes.  Near-by  capillaries 
become  irregular  in  outline  ;  at  certain  points  bulging  occurs, 
and  at  these  points  new  capillaries  develop,  extend  into  the 
mass  of  fibroblasts,  and  join  new  capillaries  of  the  opposite 
side.  The  reparative  material  is  now  said  to  be  organized ; 
it  has  become  granulation-tissue.  The  fibroblasts  become 
spindle-shaped  and  develop  into  interlacing  fibers  (Fig.  31). 
The  tissue  is  now  fibrous  tissue ;  it  contracts  strongly,  and 
finally  most  of  the  capillaries  are  obliterated  by  pressure.  In 
such  a  slight  wound  the  reaction  to  injuiy  is  chiefly  noted  in 
the  cells  of  the  part,  and  the  vessels  and  leukocytes  play  but 
a  small  part  in  repair.  The  exudation  is  so  scanty  that  there 
is  practically  no  swelling  unless  some  arises  from  venous 
obstruction.  The  vessels  are  so  slightly  affected  that  there 
is    no    redness.      The    final    step   in  healing    is   contraction 

of  the  fibrous  tissue  and  the  cov- 
,««o.e  =••  ■  ' y.  ering  of  the  surface  with  epithe- 
''<^''  '  '       hum,    which     springs    from     the 

y      epithelial    cells    upon    the    edges. 
This  final  process  is  called  "  cica- 
trization," and  consists  in  contrac- 
ts '       tion  of  the  wound  and   skimming 
/  over  with    epithelium.     The  "  im- 

mediate union "  of  some  writers 
Fig.  3i.-Ceiis^d^e^vdoping  into  fibers     ^^^^^^j.    occurs.     This    term  mcans 

the  union  of  microscopical  parts 
to  their  counterparts  without  any  effort  at  repair.  A  first 
union  is  effected  always  by  clotted  blood  and  coagulated 
exudate,  next  by  proliferating  cells,  and  finally  by  fibrous 
tissue.  A  wound  healing  by  first  intention  exhibits  no  evi- 
dence of  inflammation.  There  is  some  slight  tenderness,  but 
no  actual  pain.  A  certain  amount  of  swelling  arises  because 
of  exudation  of  fluid  from  the  blood,  and  the  coagulation  of 
this  fluid  makes  the  wound-edges  hard.  Venous  obstruc- 
tion leads  in  some  cases  to  a  considerable  fluid  swelling. 
In  a  more  extensive  incised  wound  many  vessels  are  cut. 
After  oozing  ceases  the  vessels  are  closed  by  clots  con- 
tinuous with  the  clot  between  the  sides  of  the  wound.     An 


HEALIXG  BY  FIRST  IXTEXTIOX. 


107 


Fig.  34. 

Figs.   32-^4.— Healing  by  first  intention  (after   Pick)  :    a,  skin :  b,  fibroblasts ;  c,   d,  e, 

capillaries.     Fig.  32.  Clot  in  the  vessels  continuous  with   clot  between  the  edares  of  the 

wound.     Fig.   33,  Migration  of  leukocytes   into  the  perivascular  tissues  and  mto  the  clot 

between  the  edges  of  the  wound.     Fig.  34,  Formation  of  new  capillaries. 

exudation   of  plasma  from   the  vessels  and  of  lymph  from 
the  lymph-spaces  takes  place.     Leukocytes  in   great  num- 


I08  REPAIR. 

bers  invade  the  wound-edges  and  the  exudate,  and  the  exu- 
date clots.  This  mass  of  blood-clot,  plasma-clot,  and 
leukocytes  used  to  be  known  as  "  coagulable  lymph."  The 
leukocytes  actively  eat  up  the  clot,  and  by  the  end  of  the 
third  day  occupy  the  space  formerly  occupied  by  the  clot. 
The  fixed  connective-tissue  cells  and  endothelial  cells  multi- 
ply, and  grow  into  the  mass  of  leukocytes,  eating  up  many 
of  the  leukocytes,  and  finally  join  the  fibroblasts  of  the  other 
side  of  the  wound.  Some  leukocytes  proliferate,  others  get 
back  into  the  lymph-spaces.  New  capillaries  form  from  the 
capillaries  at  the  wound-margins.  By  the  end  of  the  first 
week  the  fibroblasts  begin  to  assume  various  outlines,  send- 
ing out  poles  or  branches  or  becoming  spindle-shaped. 
These  spindle-shaped  cells  become  fibers,  and  the  fibers  of 
the  new  tissue  interlace  and  strongly  contract.  Thus  the 
edges  are  pulled  firmly  together.  Finally  new  epithelium 
derived  from  epithelium  at  the  edges  forms  and  grows  over 
the  wound  (Figs.  32-34),  and  exhibits  the  stages  of  repair 
in  healing  by  first  intention.  During  the  first  twenty-four 
hours  after  a  large  wound  begins  to  heal  by  first  intention 
the  discharge  of  bloody  serum  is  most  plentiful,  but 
after  this  period  it  becomes  very  scanty  and  soon  ceases 
entirely,  and  can  be  much  diminished  in  quantity  in  the  first 
day  by  the  application  of  pressure.  Warren  says  that  after 
a  hip-joint  amputation  over  a  pint  of  bloody  serum  flows  out 
during  the  first  twenty-four  hours.  In  a  large  wound 
special  methods  to  secure  drainage  are  required.  In  a  small 
wound  drainage  is  obtained  between  the  stitches.  The  use 
of  irritant  germicides  in  a  wound  greatly  increases  the 
amount  of  discharge  and  renders  drainage  necessary  in  even 
a  comparatively  small  wound  for  the  first  twenty-four  hours. 
In  an  aseptic  wound,  as  a  rule,  one-half  of  the  stitches  are 
removed  on  the  fifth  or  sixth  day  and  the  remainder  on  the 
eighth  day,  but  for  two  weeks  more  the  wound  should  be 
rested  and  supported,  as  the  new  tissue  is  not  very  resistant 
to  infection.  Aseptic  fever  always  arises  when  much  exuda- 
tion is  given  out  and  not  quickly  and  perfectly  drained. 
Aseptic  fever  is  due  to  the  absorption  of  aseptic  pyrogenous 
material  (p.  115).  If  an  incised  wound  becomes  infected, 
the  pyogenic  organisms  destroy  the  bond  of  union  which 
is  forming  between  the  wound-edges  by  liquefying  the  inter- 
cellular substance.  As  a  consequence  the  wound-edges  are 
widely  separated  by  pus. 

What  used  to  be   known  as   "healing  by  blood-clot "  is 
healing  by  first  intention.     If  there   is  a  considerable  gap 


HEALING  BY  SECOND   INTENTION. 


109 


between  the  edi;es  of  an  aseptic  wound,  and  the  gap  is  filled 
with  a  blood-clot,  healing  goes  on  in  the  same  manner  as 
when  the  gap  is  narrow,  although  more  corpuscles,  more  exu- 
date, and  more  fibroblasts  are  required  to  effect  repair. 

Healing  by,  Second  Intention. — Healing  of  a  wound 
in  which  there  is  a  large  cavity  in  the  tissue  or  in  which  the 
edges  have  gaped  apart  is  known  as  healing  by  granulation 
or  healing  by  "  second  intention."  It  is  effected  in  the  same 
manner  as  healing  by  "  first  intention,"  the  processes  in  the 
two  cases  being  practically  identical.  As  a  matter  of  fact, 
in  healing  by  granulation  there  is  usually  wound-infection. 
As  a  result  of  infection  intercellular  substance  is  peptonized, 
many  reparative  cells  are  cast  off,  and  repair  can  be  effected 
only  after  the  formation  of  enormous  numbers  of  fibroblasts 
and  the  expenditure  of  considerable  time.  It  requires  much 
longer  for  an  infected  wound  to  heal  than  for  an  incised 
wound    to    be    repaired,    and    an    infected   wound  can  heal 


Fig.  35. — Development  of  a  blood-vessel  in  mesentery  of  an  embryo  (Warren). 

only  by  granulation.  After  the  infliction  of  a  wound  the 
oozing  ceases  because  thrombi  form  in  the  vessels  and  some 
clot  gathers  in  tissue-gaps  and  interstices.  Exudation  begins 
and  leukocytes  migrate  into  the  exudate  and  into  the  walls 
of  the  wound.     In  an  hour  or  two  the  surface  of  the  wound 


no 


REPAIR. 


becomes  distinctly  glazed  or  glistening,  because  of  the  for- 
mation and  coagulation  of  fibrin.  The  exudation  is  at  first 
thin  and  red,  and  it  becomes  so  profuse  as  to  wash  away  the 
discolored  fibrin  coat.  In  a  few  days  the  discharge  usually 
becomes  purulent.  The  connective-tissue  cells  proliferate 
and  form  fibroblasts,  and  the  fibroblasts  multiply  to  close  the 
wound.     From   adjacent   capillaries    new   capillaries    form. 


Fig.  36. — Cicatricial  tissue;   X  670  (Fowler). 

This  formation  takes  place  as  follows:  A  portion  of  a  cap- 
illary thickens  and  a  whip-like  process  comes  off  from  the 
the  thickened  part.  This  process  fuses  with  a  second  filament 
budded  from  another  or  from  the  same  capillary,  or  runs 
straight  out  as  a  terminal  vessel.  The  filaments  after  a  time 
are  hollowed  out  from  within,  protoplasmic  tubes  are  formed. 


Fig.  37. — Blood-vessels  in  granulation  (Gross 


and  endothelial  cells  develop  from  the  protoplasm.  In 
some  cases  a  tubular  prolongation  comes  off  from  a  capillary 
directly.  Fig.  35  shows  the  formation  of  a  capillary.  In  a 
wound  healing  by  granulation  these  newly  formed  capillaries 
run  among  the  fibroblasts,  and  some  of  them  run  perpendicu- 
larly to  the  surface,  or  a  loop  forms  and  reaches  the  surface. 
The  surface  of  a  granulating  wound  is  covered  with  migrated 


HEALIXG  B  Y  SECOND   INTENTION.  I  1 1 

leukocytes,  and  directly  under  these  are  the  new  vascular 
strings  or  loops.  Vascular  strings  or  loops  covered  with 
white  corpuscles  are  called  granulations  (Fig.  37  shows  a 
granulating  surface).  When  the  discharge  becomes  puru- 
lent, many  leukocytes  and  fibroblasts  are  destroyed,  inflam- 
mation increases,  exudation  becomes  profuse,  and  cellular 
multiplication  widespread  and  rapid  in  order  to  make  up  for 
the  cells  lost  by  microbic  action.  Gradually  the  gap  is  filled. 
As  it  is  being  filled  the  older  fibroblasts  in  the  deeper  la}-ers 
of  the  edges  and  base  of  the  wound  are  converted  into  cica- 
tricial, fibrous,  or  scar  tissue.  As  the  granulations  rise  to  a 
higher  level  at  the  surface  the  area  of  fibrous  tissue  becomes 
broader  at  the  base  and  margins,  and  this  young  fibrous  tissue 
contracts.  By  contracting  it  draws  the  edges  of  the  wound 
nearer  together  and  thus  lessens  the  area  of  the  surface  which 
must  be  co\-ered  with  epithelium.  When  the  granulations 
reach  the  level  of  the  cutaneous  surface  the  epithelial  cells 
at  the  margin  of  the  wound  proliferate,  and  young  epithelial 
cells,  constituting  a  bluish  or  opalescent  film,  grow  over  the 
granulations.  Epithelium  comes  onl}-  from  epithelium. 
Granulations  are  ne\'er  converted  into  epithelium.  The 
epithelial  covering  comes  only  from  the  epithelium  at  the 
wound-margins,  unless  there  be  epithelial  remains  in  the 
wound ;  for  instance,  an  undestroyed  papilla,  sweat-duct,  or 
hair-follicle.  The  process  of  covering  the  surface  with 
epithelium  is  known  as  epidermization.  Before,  during,  and 
for  a  time  after  epidermization  the  fibrous  tissue  of  the 
walls  and  base  of  the  wound  contracts.  Thus  the  wound- 
margins  are  pulled  and  held  nearer  together,  the  gap 
to  be  bridged  is  diminished  in  size,  the  danger  of  tearing 
apart  of  the  epithelial  coat  is  lessened,  man}'  capillaries 
are  destroyed  by  pressure,  and  the  scar  becomes  firm,  Avhite, 
and  puckered.  Cicatrization  consists  in  the  covering  of  the 
granulations  with  epithelium  and  also  in  the  contraction 
of  the  new  fibrous  tissue.  If  infection  is  severe,  destruction 
will  exceed  repair  and  healing  will  not  occur.  In  such  a 
case  there  is  coagulation-necrosis  of  granulation-tissue,  and 
the  wound  becomes  covered  with  tissue-remains  (aplastic 
lymph).  If  granulations  rise  above  the  cutaneous  level, 
healing  will  not  take  place,  because  the  epithelium  cannot 
grow  over  the  surface.  A  wound  in  this  condition  is  said 
to  possess  exuberant  granulations,  or  "  proud  flesh."  In 
some  cases  the  granulations  are  pale  from  insufficient  blood- 
supph',  and  in  others  edematous  from  venous  congestion. 
Contraction  of  the  fibrous  tissue  mav  be  insufficient  because 


1 1 2  REPAIR. 

there  is  adhesion  to  deep  unyielding  fascia  or  to  perios- 
teum. Excessive  contraction,  so  often  seen  after  burns, 
often  produces  terrible  deformity.  The  scars  or  cicatrices 
of  burns  contain  much  elastic  tissue.  Infected  wounds  and 
ulcers  heal  by  second  intention. 

Healing:  by  Third  Intention. — This  consists  in  the 
union  of  two  granulating  surfaces,  the  granulations  of  one 
side  fusing  with  the  granulations  of  the  other  side.  It  is 
seen  in  the  union  of  collapsed  abscess-walls.  The  surgeon 
occasionally  seeks  to  obtain  union  by  third  intention  by 
approximating  two  granulating  surfaces.  If  the  surfaces  are 
aseptic,  he  will  often  succeed.  The  process  is  known  as 
"secondary  suturing."  It  is  not  unusual  to  pack  a  wound 
with  iodoform  gauze  to  control  oozing.  When  this  is  done 
it  is  customary  to  pass  the  sutures,  but  not  to  tie  them. 
After  a  few  days  the  gauze  is  removed  and  the  sutures  are 
tied.  This  plan  renders  healing  much  more  rapid  than 
could  be  obtained  by  the  process  of  second  intention. 

Healing  of  Subcutaneous  Wounds. — Blood  fills  the 
tissue-gap  and  the  blood  clots.  Plasma  exudes  and  cor- 
puscles migrate  into  the  clot  and  the  tissue  about  it. 
The  clot  is  eaten  up  by  the  leukocytes.  The  connective- 
tissue  cells  and  the  endothelial  cells  of  the  adjacent  tissue 
proliferate  and  form  fibroblasts,  and  fibroblasts  multiply  and 
replace  the  clot.  The  area  of  fibroblasts  is  vascularized  by 
the  formation  of  new  capillaries,  and  fibrous  tissue  forms  and 
strongly  contracts. 

Healing  of  Wounds  in  Non-vascular  Tissues. — In 
a  trivial  wound  of  the  cornea  a  few  leukocytes  gather  from 
the  lymph-spaces  and  a  few  of  the  fixed  cells  proliferate.  In 
a  more  severe  wound  the  episcleral  vessels  dilate,  plasma 
and  corpuscles  pass  into  the  corneal  lymph-spaces,  and 
repair  is  effected  as  in  vascular  tissue. 

Repair  in  cartilage  takes  place  as  in  the  cornea.  In  both 
structures  any  marked  injury  is  repaired  by  fibrous  tissue, 
and  the  scar  is  permanent. 

Cell-division. — The  multiplication  of  connective-tissue 
cells  in  repair  may  be  by  direct,  but  is  usually  by  indirect, 
cell-division.  Direct  cell-division  consists  in  division  of  the 
nucleus  followed  by  division  of  the  entire  cell. 

Indirect  cell-division,  or  karyokinesis,  takes  place  after 
remarkable  changes  in  the  nucleus.  The  membrane  of  the 
nucleus  disappears  ;  the  nuclear  network  becomes  first  close 
and  then  more  open  ;  and  the  cells  become  round,  if  not  so 
before.     The  network  of  the  nucleus,  now  consisting  of  one 


REPAIR    OF  MUSCLE. 


113 


long  fiber,  takes  the  shape  of  a  rosette ;  next  it  takes  a  star- 
form — the  aster  stage  ;  two  sets  of  V's  next  form — the  equa- 
torial stage  ;  an  equatorial  line  appears  and  widens,  and  each 
set  of  V's  retreats  toward  a  pole.  Thus  two  new  nuclei  are 
formed,  each  polar  V  passing  in  inverse  order  through  the 
previous  changes  of  shape,  and  the  protoplasm  of  the  orig- 
inal cell  collecting  about  each  nucleus  (Fig.  38). 

Repair  of  Nerve. — Divided  nerve,  when  the  ends  are 
approximated,  can  regenerate.  The  ends  become  united  by 
new  connective  tissue ;  this  new  tissue  is  a  bridge  for  nerve- 
cells,  and  nerve  gradually  forms  in  it  by  the  growth  of  cells 
from  both  the  central  and  distal  ends,  the  cells  finally  meet- 


Fig.  38. — Forms  assumed  by  a  nucleus  dividing  (Green,  from  Flemming). 


ing.  The  fibrous  tissue  is  not  converted  into  nervous  tissue. 
If  the  ends  are  not  approximated,  they  join  by  fibrous  tissue, 
the  distal  end  atrophies,  the  proximal  end  becomes  bulbous, 
and  nerve-cells  do  not  grow  into  the  fibrous  tissue  or  join 
the  ends  of  the  nerv'e.  The  above  view  is  entertained  by 
Mayer  and  Eichhorst.  Waller  holds  that  repair  is  effected 
by  the  central  end  alone.  If  a  nerve  has  been  divided,  it 
should  be  sutured. 

Repair  of  Muscle. — When  a  muscle  is  divided,  the 
ends  retract  and  a  considerable  space  is  left  between  them. 
Blood  flows  into  the  space  between  the  ends  and  also 
between  individual  fibers  of  the  injured  muscle,  and  the  blood 
clots.  Exudation  of  plasma  occurs  and  migration  of  cor- 
puscles takes  place.  Fibroblasts  are  formed,  granulation- 
tissue  is  formed  by  vascularization  of  the  mass  of  fibroblasts, 
and  granulation-tissue  is  converted  into  scar-tissue,  but 
not  into  muscle.  After  slight  injuries  muscular  regenera- 
tion   does    occur    to    some    slight    extent,  either   from    the 


1 14  REPAIR. 

multiplication  of  living  muscle-cells  or  by  metamorphosis  of 
fibrous  tissue.  If  a  muscle  has  been  divided,  it  should  be 
sutured.  This  process  insures  more  rapid  repair  and  secures 
a  better  functional  result,  and  is  probably  followed  by  some 
muscular  regeneration. 

Repair  of  Tendon. — When  a  tendon  is  divided  the 
ends  retract,  and  the  sheath,  as  a  rule,  becomes  filled  with 
blood-clot.  The  blood-clot  is  rapidly  removed,  fibroblasts 
replacing  it.  This  new  tissue  arises  from  the  sheath,  and 
the  cut  ends  do  not  participate  in  the  process.  Granulation- 
tissue  is  formed ;  this  is  converted  into  fibrous  tissue,  and 
after  a  time  the  fibrous  tissue  becomes  true  tendon.  If  no 
blood-clot  forms  in  the  sheath,  the  walls  of  this  structure 
collapse  and  adhere,  and  the  separated  tendon-ends  are  held 
together  by  a  flat  fibrous  band  formed  from  the  collapsed 
sheath  (Warren's  Surgical  Pathology). 

Repair  of  Bone. — When  a  bone  is  broken,  a  large 
blood-clot  forms  in  the  medullary  canal,  between  the 
broken  ends,  below  and  outside  of  the  periosteum.  Masses 
of  new  cells  are  formed.  Granulation-tissue  replaces  the 
blood-clot  as  the  clot  is  removed  by  leukocytes.  Granu- 
lation-tissue becomes  fibrous  tissue,  and  the  fibrous  tissue 
in  many  places  becomes  cartilaginous.  In  the  second  week 
lime-salts  begin  to  deposit  and  bone  forms. 

Repair  of  Blood-vessels. — If  an  artery  is  cut  across 
and  ligated,  a  clot  forms  within  its  lumen  and  about  its 
divided  end.  The  internal  clot  reaches  up  to  the  first  col- 
lateral branch.  Exudation  of  plasma  and  migration  of  cor- 
puscles take  place  from  the  vasa  vasorum.  The  clot  becomes 
filled  with  leukocytes,  which  gradually  destroy  it.  Fibro- 
blasts form,  the  clot  is  replaced  by  granulation-tissue,  granu- 
lation-tissue by  fibrous  tissue,  the  fibrous  tissue  contracts, 
and  the  artery  is  converted  into  a  fibrous  cord.  A  divided 
vein  heals  in  the  same  manner,  except  that  the  internal  clot 
may  not  reach  the  first  collateral  branch  or  may  extend  far 
above  it. 

Repair  of  Skin. — The  fibrous  structure  is  repaired  by 
fibrous  tissue.  Hair-follicles,  sweat-glands,  and  sebaceous 
glands  are  not  reformed.  The  epithelial  layer  is  regenerated 
by  the  proliferation  of  adjacent  epithelial  cells. 


TRA  UMA  TIC  FE  VERS.  \  I 


V.  SURGICAL  FEVERS. 


The  surgeon  encounters  fever  as  a  result  of  an  inflamma- 
tion or  an  aseptic  wound,  in  consequence  of  infection,  and  in 
certain  maladies  of  the  nervous  system.  It  is  important  to 
remember  that,  while  elevated  temperature  is  generally  taken 
as  a  gauge  of  the  intensity  of  fever,  it  is  not  a  certain  index. 
There  may  be  fever  with  subnormal  temperature  (as  in  the 
collapse  of  typhoid  or  pneumonia),  and  there  may  be  elevated 
temperature  without  true  fever  (as  in  certain  diseases  of  the 
nervous  system).  It  is  true,  however,  that  elevation  of  tem- 
perature is  almost  always  noted,  and  is  usually  accepted  as 
the  measure  of  the  height  of  fever. 

The  essential  phenomena  of  fever,  according  to  Maclagan, 
are — (i)  wasting  of  nitrogenous  tissue;  (2)  increased  con- 
sumption of  water ;  (3)  increased  elimination  of  urea ;  (4) 
increased  rapidity  of  circulation;  and  (5)  preternatural  heat. 

Traumatic  fevers  follow  a  traumatism  and  attend  the 
healing  or  infection  of  a  wound.  The  forms  are — (i)  benign 
traumatic  fever  ;  (2)  malignant  traumatic  fever. 

Benig-n  traumatic  fever  is  divided  into  two  classes — the 
aseptic  and  the  septic.  There  is  but  one  form  of  aseptic 
fever,  the  post-operation  rise.  The  septic  benign  fevers  are 
surgical  fever  and  suppurative  fever.  The  malignant  trau- 
matic fevers  are  sapremia,  septic  infection,  and  pyemia.  In 
this  section  we  discuss  only  the  benign  fevers. 

Aseptic  fever  often,  but  not  always,  appears  after  a  thor- 
oughly aseptic  operation  and  after  a  simple  fracture  or  a  con- 
tusion. It  is  not  preceded  by  a  chill,  by  chilliness,  or  by  a 
feeling  of  illness.  It  may  appear  during  the  evening  of  the 
day  of  operation  or  not  until  the  next  day,  and  reaches  its 
highest  point  by  the  evening  of  the  second  day  (100°  to 
103°  F.).  This  elevation  is  spoken  of  as  the  "post-operation 
rise."  Besides  the  fever  there  are  no  obvious  symptoms ; 
the  patient  feels  well,  sleeps  well,  and  often  wants  to  sit  up ; 
there  are  no  rigors  and  there  is  no  delirium.  The  wound  is 
free  from  pain  and  appears  entirely  normal.  Blood  examina- 
tion shows  leukocytosis.  This  fever  is  due  to  absorption  of 
pyrogenous  material  from  the  wound-area,  the  material  being 
obtained  from  clot  or  inflammatory  exudate,  or  from  both. 
Many  observers  believe  that  the  pyrogenous  elemient  is. 
fibrin-ferment,  which  is  absorbed  from  disintegrating  blood- 
clot  and  coagulating  exudate.  Warren  thinks  the  fever  is  due 
to   fibrin-ferment,   and   "  also   to    other   substances    slightly 


Il6  SURGICAL    FEVERS. 

altered  from  their  original  composition  during  life."     Some 
have  asserted  that  the  fever  is  due  to  nervous  shock. 

Schnitzler  and  Ewald  have  recently  studied  aseptic  fever.^ 
These  observers  maintain  that  aseptic  fev^er  can  exist  when 
no  fibrin-ferment  is  free  in  the  blood,  that  fibrin-ferment  can 
be  free  in  the  blood  when  there  is  no  fever,  and,  in  conse- 
quence, that  fibrin-ferment  is  not  the  cause  of  the  elevation 
of  temperature.  They  rule  out  of  consideration  nervous 
shock  as  a  cause,  and  assert  that  a  combination  of  sev^eral 
factors  is  responsible,  nucleins  and  albumoses  which  are  set 
free  by  traumatism  being  looked  upon  as  the  most  active 
causative  agents.  The  presence  of  nuclein  in  the  blood  in 
aseptic  fever  is  indicated  by  leukocytosis  and  by  the  increase 
of  the  alloxur  bodies  (including  uric  acid)  in  the  urine.  The 
capacity  of  nucleins  and  albumoses  to  cause  fever  is  greater 
in  the  tubercular  than  in  the  non-tubercular.  The  diagnosis 
of  aseptic  traumatic  fever  is  only  made  after  a  careful  exami- 
nation has  assured  the  surgeon  there  is  no  obscure  or  hidden 
area  of  infection. 

In  some  cases  aseptic  fever  may  appear  after  an  opera- 
tion, and  later  be  replaced  by  a  septic  fever.  If  the  tempera- 
ture remains  high  after  a  few  days,  if  other  symptom.s  appear, 
or  if  after  the  temperature  becomes  normal  it  again  rises,  the 
wound  should  be  examined  at  once,  as  trouble  almost  cer- 
tainly exists. 

Traumatic  or  surgical  fever  is  seen  as  a  result  of  infected 
wounds  where  there  is  decided  inflammation,  but  no  pus.  The 
real  cause  is  the  presence  of  fermentative  bacteria  in  the  wound 
and  the  absorption  of  their  toxic  products.  The  most  active 
and  commonly  present  organisms  are  those  of  putrefaction. 
Surgical  fever  ceases  as  soon  as  free  discharge  occurs,  and 
the  appearance  of  such  a  fever  is  an  indication  for  instant  drain- 
age. The  condition  is  ushered  in  two  or  three  days  after  the 
operation  by  chilly  sensations  and  general  discomfort.  The 
temperature  rises  pretty  sharply,  ascends  with  ev'ening  exacer- 
bations and  morning  remissions,  and  reaches  its  height  about 
the  third  or  fourth  day,  when  suppuration  sets  in  ;  the  tem- 
perature begins  to  drop  when  pus  forms,  if  the  pus  has  free 
exit,  and  reaches  normal  at  the  end  of  a  week  (see  Suppurative 
Fever).  The  temperature  may  reach  104°  F.  or  more,  but 
rarely  rises  above  103°  F.  The  patient  has  the  general  phe- 
nomena of  fever  :  Thij'st,  anorexia,  nausea,  dry  and  coated 
tongue,  constipation,  pain  in  the  back  and  legs,  and  headache. 

^  See  Archiv  fiir  klinische  Median,  Bd.  liii.,  H.  3,  1896;  also  statement  of 
their  views  in  Medical  Record,  Dec.  19,  1896. 


OTJIEK   FORMS   OF  FEVER.  WJ 

The  urine  is  scanty  and  high  colored.  Blood  examination 
shows  leukocytosis.  The  wound  is  painful,  tender,  swollen, 
discolored,  and  often  foul,  and  stitch-abscesses  may  form. 
Some  or  all  of  the  stitches  must  be  cut,  and  the  area  should 
be  asepticized,  and  packed  with  iodoform  gauze  or  drained 
by  a  tube.  The  fact  that  this  fever  is  apt  to  cease  when 
suppuration  begins  led  the  older  surgeons  to  hope  for  pus 
and  to  endeavor  to  cause  it  to  form.  A  severe  grade  of 
surgical  fever,  such  as  arises  when  there  is  putrefaction  in  a 
large  and  ill-drained  wound,  is  known  as  sapremia  (p.  174). 

Suppurative  Fever. — This  fe\'er,  which  is  due  to  the  ab- 
sorption of  the  toxins  of  pyogenic  organisms,  occurs  after 
suppuration  has  begun,  is  found  when  the  pus  has  not  free 
exit,  and  is  an  intoxication  rather  than  an  infection.  It  can 
follow  or  be  associated  with  surgical  fever,  or  may  arise  in 
cases  in  which  surgical  fever  has  not  existed.  Suppuration 
in  a  wound  is  indicated  by  a  rapid  rise  of  temperature — pos- 
sibly by  a  chill.  The  fever  rises  to  a  considerable  height,  it 
shows  morning  remissions  and  evening  exacerbations,  and 
as  the  temperature  begins  to  fall  toward  morning  sweating 
occurs.  The  patient  is  much  exhausted  and  presents  the  phe- 
nomena of  fever  previously  described.  The  skin  about  the 
wound  becomes  swollen,  dusky  in  color,  and  edematous, 
pain  becomes  pulsatile,  and  much  tenderness  develops. 
Blood  examination  shows  leukocytosis.  The  wound  must 
at  once  be  drained  and  asepticized.  In  a  chronic  suppura- 
tion, such  as  occurs  in  the  mixed  infection  of  a  tubercular 
area,  there  exists  a  fever  with  marked  morning  remissions 
and  vesperal  exacerbations,  attended  with  drenching  night- 
sweats,  emaciation,  diarrhea,  and  exhaustion.  This  is  known 
as  "  hectic  fever ;"  it  is  really  a  chronic  suppurative  fever.  The 
treatment  of  hectic  fever  consists  in  the  drainage  and  disin- 
fection, if  possible,  the  excision  of  the  infected  area,  the  em- 
ployment of  a  nutritious  diet,  stimulants,  tonics,  remedies  for 
the  exhausting  sweats,  and  free  access  of  fresh  air. 

Other  Forms  of  Fever. — Fever  of  Tension. — When 
there  is  great  tension  upon  the  stitches  the  spots  Avhere  the 
stitches  perforate  ulcerate  and  some  fever  arises.  To  relieve 
the  fever  of  tension  cut  one  or  several  stitches.  This  fever 
is  in  some  cases  surgical,  and  in  some  suppurative,  according 
as  to  whether  the  infective  organisms  cause  fermentation  or 
suppuration. 

Fever  of  Iodoform  Absorption  (see  p.  29). 

Malaria. — It  is  wise  to  examine  the  blood  in  supposed 
septic  fevers,  for  only  by  this  means  can  malaria  be  excluded. 


1  I  8  SUPPURA  riON  AND   ABSCESS. 

It  is  more  common  to  mistake  sepsis  for  malaria  than  malaria 
for  sepsis. 

Surgical  Scarlet  Fever. — It  is  maintained  by  some  writers 
(notably  Victor  Horsley  and  Sir  James  Paget)  that  a  child  is 
rendered  especially  susceptible  to  scarlet  fever  by  the  shock 
of  a  surgical  operation.  Scarlet  fever  which  develops  after 
an  operation  is  spoken  of  as  surgical  scarlet  fever.  Warren 
quotes  Thomas  Smith  as  having  had  ten  cases  of  scarlet  fever 
in  forty-three  operations  for  lithotomy  in  children.  The 
puerperal  state  is  supposed  also  to  predispose  to  scarlet 
fever.  Some  surgeons  hold  that  an  attack  of  scarlet  fever 
after  an  operation  is  a  mere  coincidence.  Others  maintain, 
and  with  great  show  of  reason,  that  a  red  scarlatiniform 
eruption  appearing  after  an  operation  rarely  indicates  genuine 
scarlet  fever,  but  usually  points  to  infection,  as  such  eruptions 
are  known  occasionally  to  arise  in  septicemia. 

Hoffa  has  discussed  this  subject  elaborately.  He  con- 
cludes that  four  types  of  eruption  can  follow  operation:  (i) 
a  vaso-motor  disturbance  due  to  irritation  of  sensory  nerves, 
and  manifested  by  a  transient  urticaria  or  erythema ;  (2)  a 
toxic  erythema  due  to  absorption  of  aseptic  pyrogenous  ma- 
terial from  the  injured  area — the  absorption  of  carbolic  acid, 
iodoform,  or  corrosive  sublimate,  or  the  effect  of  ether;  (3) 
an  infectious  rash  which  is  sometimes  found  in  septicemia  or 
pyemia,  and  due  to  minute  emboli  composed  of  bacteria, 
which  emboli  lodge  in  the  capillaries ;  (4)  true  scarlet  fever, 
with  the  usual  symptoms  and  complications,  the  organisms 
having  entered  by  way  of  the  wound,  and  the  eruption  often 
beginning  at  the  wound-edges  (quoted  in  Warren's  Siirgical 
Pathology^. 

Urinary  Fever  and  Urethral  Fever  (see  p.  1016). 

VI.     SUPPURATION  AND  ABSCESS. 

Suppuration  is  a  process  in  which  tissues  and  inflamma- 
tory exudates  are  liquefied  by  the  action  of  pyogenic  organ- 
isms, and  it  is  a  common  result  of  microbic  inflammation. 
The  organisms  which  are  responsible  are  referred  to  on 
page  39.  Staphylococci  produce  local  suppuration  ;  strep- 
tococci cause  spreading  suppuration.  Pyogenic  bacteria 
liquefy  exudate  by  peptonizing  it.  The  pyogenic  organisms 
are  very  irritant,  and  when  deposited  cause  inflammation ; 
inflammation  leads  to  exudation,  but  the  exudate  cannot 
coagulate  or  coagulates  but  imperfectly,  because  it  is  pepto- 
nized by  the  ferment  of  the  micro-organisms.     If  an  area  of 


SUPPURATION.  119 

embr}-onic  tissue  is  invaded  by  the  pyogenic  micro-organisms, 
it  is  promptly  peptonized.  The  peptonizing  action  is  upon 
the  fibrinous  elements  of  an  exudate  and  upon  the  inter- 
cellular substance  of  embr)-onic  or  granulation-tissue.  Cells 
are  separated  from  intercellular  substance,  and  in  conse- 
quence degenerate  and  die.  Peptonized  exudate  or  em- 
brx'onic  tissue  is  called  pus.  In  suppurations  induced  by 
staphylococci  a  barrier  of  leukocj-tes  is  first  formed  around 
the  region  of  irritation,  this  barrier  is  reinforced  by  fibro- 
blasts, and  the  pus  is  imprisoned  and  kept  from  spreading. 
In  inflammations  induced  by  streptococci  the  peptonizing 
action  of  the  organisms  is  so  great  that  no  barrier  of  white 
blood-cells  or  of  proliferating  connective-tissue  cells  forms  in 
time  to  imprison  the  micro-organisms ;  hence  the  suppura- 
tion spreads  \\'idely.  Suppuration  can  be  induced  by  the 
injection  of  pyogenic  bacteria,  by  their  entr}-  through  a 
wound,  and  by  rubbing  them  upon  the  skin.  In  some  rare 
instances,  especially  when  the  diet  has  been  putrid,  they  may 
enter  through  the  blood  and  lodge  at  a  point  of  least  resist- 
ance. When  a  medullar}*  canal  suppurates  after  a  chill  to 
the  surface  or  after  a  blow  that  does  not  cause  a  wound,  we 
know  that  the  organisms  must  have  arrived  by  means  of 
the  blood.  Organisms  which  reach  a  point  of  least  resistance 
through  the  blood  come  from  some  atrium  of  infection  which 
may  be  discoverable  or  wliich  may  not  be  found.  The  entr\- 
of  pyogenic  bacteria  does  not  necessarily  cause  suppura- 
tion, as  the  healthy  human  body  can  destroy  a  considerable 
number,  even  if  given  in  one  "  dose ;  "  but  a  large  number 
in  a  healthy,  or  even  a  small  number  in  an  unhealthy, 
organism  almost  certainly  leads  to  pus  formation.  The  pus 
of  all  acute  abscesses  contains  bacteria  of  suppuration,  but 
the  pus  of  tubercular  abscesses  does  not.  unless  there  be 
a  mixed  infection  ;  in  other  words,  pure  tubercular  pus  is  not 
pus  at  all. 

Can  suppuration  be  induced  without  micro-organisms  ?  It 
is  true  that  the  injection  of  irritants  can  cause  the  formation 
of  a  thin  fluid  which  contains  no  organisms,  but  is  this  non- 
bacterial pus  really  pus  ?  The  same  sort  of  fluid  is  formed 
by  injecting  cultures  of  pus  cocci  which  have  been  rendered 
sterile  by  heat,  the  organisms  being  killed,  a  ferment  con- 
tained in  the  bacterial  cells  being  the  active  agent.  Spu- 
rious or  "aseptic"  pus  does  not  concern  us,  as  it  is  never 
found  practically.  Impaired  health  or  an  area  of  lowered 
\"italit\-  predisposes  to  suppuration.     The  lymphatic  glands, 


I20 


SUPPURATION  AND   ABSCESS. 


medulla  of  bones,  serous  membranes,  and  connective  tissue 
are  especially  prone  to  suppurate. 

Pus  may  form  in  twenty-four  hours  after  bacteria  are 
deposited,  or  it  may  not  form  for  days.  The  older  surgeons 
claimed  that  pus  could  do  good  by  protecting  granulations 
and  separating  disorganized  tissue.  It  is  now  held  that  it  is 
absolutely  harmful  by  melting  down  sound  tissue  and  poi- 
soning the  entire  organism.  Modern  surgery  has  to  a  great 
degree  abolished  pus. 

If  pus  stands  for  a  time,  it  separates  into  two  portions — 
(i)  a  watery  portion,  the  liquor  puris  or  pus-serum,  contain- 
ing peptone,  fat,  microbic  products,  osmazone,  and  salts,  and 
not  tending  to  coagulate ;  (2)  a  solid  portion,  or  sediment  of 
micro-organisms  of  suppuration,  pus-corpuscles  (Fig.  39),  and 


(3      :.:r'"}^. 


jm 


^"'■^    "^     «S         o 


-S^  -  '' 


Fig.   39. — Fragmentation  of  nucleus  in  leukocytes  undergoing  transformation  into  pus- 
corpuscles  (Senn). 


broken-down  tissue.  The  pus-corpuscles  are  either  white 
blood-cells  or  altered  connective-tissue  cells.  Some  of  them 
are  dead,  some  have  ameboid  movements,  some  are  fatty, 
others  are  granular  and  contain  more  than  one  nucleus,  and 
all  are  degenerating.  A  pus-cell  is  waste-matter,  and  it  can- 
not aid  in  repair. 

Forms  of  Pus. — Laudable  or  healthy  pus,  a  name  long  in 
vogue,  is  a  contradiction,  no  pus  being  healthy.  In  former 
days  free  suppuration  after  an  operation  was  regarded  as  a 


SrPPURATION.  121 

favorable  indication,  and  when  it  occurred  the  surgeon  con- 
gratulated himself  that  surgical  fever  was  at  an  end.  At  the 
present  day  suppuration  after  an  operation  is  an  evidence  of 
previous  infection,  of  lack  of  care,  or  of  infection  by  the  blood. 
The  so-called  laudable  pus  is  seen  coming  from  a  healing 
ulcer,  and  is  an  opaque,  yellowish-white  or  a  greenish 
fluid  of  the  consistence  of  cream,  without  odor  or  with  a 
very  slight  odor  if  it  is  not  putrid,  and  having  a  specific 
gravity  of  about  1.030. 

Malignant,  tvatt'/y,  or  icJuvxnis  pus  is  a  thin,  watery,  putrid 
fluid.     It  is  pus  filled  with  the  organisms  of  putrefaction. 

Stinking  pus  may  be  ichorous.  If  due  to  the  bacterium 
coli  commune,  it  is  veiy  foul,  but  not  thin.  Pus  of  this  nature 
is  met  with  in  ischiorectal  abscess  and  appendiceal  abscess. 

Sanious  pus  is  a  form  of  ichorous  pus  containing  blood 
coloring-matter  or  blood.  It  is  thin,  of  a  reddish  color,  and 
very  acrid,  corroding  the  parts  that  it  comes  in  contact  with. 
It  is  found  notably  in  caries  and  carcinoma. 

Concrete  or  fibrijioiis  pus,  which  contains  flakes  of  fibrin 
or  coagulated  fibro-purulent  masses,  is  met  with  in  serous 
cavities  (joints,  pleura,  etc.).  These  masses  are  found  in 
infective  endocarditis. 

Blue  pus. — The  color  of  blue  pus  is  due  to  the  bacillus 
pyocyaneus. 

Orange  pus  is  due  to  the  action  of  sarcina  aurantiaca,  and 
appears  in  violent  inflammations. 

Serous  p2(s  is  a  thin  serous  fluid  containing  a  few  flakes. 

So-called  tubercular,  scrofulous,  or  curdy  pus  is  not  pus  at 
all,  unless  the  tubercular  area  has  undergone  pyogenic 
infection. 

So-called  gummy  pus  arises  from  the  breaking  down  of  a 
gumma  which  has  outgrown  its  own  blood-supply.  It  is 
not  pus. 

HIuco-pus  is  found  in  purulent  catarrh— that  is,  in  suppura- 
tive inflammation  of  an  epithelial  structure.  It  contains  pus- 
elements  and  epithelial  cells. 

Caseous  pus  comes  from  the  fatty  degeneration  of  pus- 
corpuscles  or  inflammator\^  exudations.  It  occurs  especially 
in  tubercular  processes.     A  caseous  mass  may  calcify. 

Suppuration  is  announced  by  the  intensification  of  all 
local  inflammatory  signs.  The  heat  becomes  more  marked, 
the  discoloration  dusky,  the  swelling  augments,  the  pain  be- 
comes throbbing  or  pulsatile,  and  the  sense  of  tension  is 
greatly  increased.  The  skin  at  the  focus  of  the  inflammation 
after  a  time  becomes  adherent  to  the  parts  beneath,  and  flue- 


122  SUPPURATION  AND   ABSCESS. 

tuation  soon  appears.  This  adhesion  of  the  skin  is  a  prepa- 
ration for  a  natural  opening,  and  is  what  is  known  as  "  point- 
ing." An  important  sign  of  pus  beneath  is  edema  of  the 
skin.  This  is  always  observed  in  a  superficial  abscess,  and  is 
sometimes  noticeable  in  empyema  or  pyothorax,  in  appendi- 
ceal abscess,  and  in  perirenal  suppuration.  The  above  symp- 
toms can  be  reinforced  and  their  significance  proved  by  the 
introduction  of  an  aseptic  tubular  exploring-needle  and  the 
discovery  of  pus.  Irregular  chills,  high  fever,  and  drenching 
sweats  are  very  significant  of  suppuration  in  an  important 
structure  or  of  a  large  area. 

Diffused  Cellulitis  or  Phlegmonous  Suppuration;  Puru- 
lent Infiltration. — This  process  may  involve  a  small  area  or 
an  entire  limb,  and  is  due  to  infection  by  the  streptococcus 
pyogenes  or  streptococcus  of  erysipelas.  The  streptococci 
are  intensely  virulent.  Barriers  of  white  corpuscles  will  not 
restrain  them,  and  tissues  break  down  before  cellular  multi- 
plication is  able  to  encompass  the  bacteria.  The  bacteria 
disseminate  through  the  lymph-spaces  and  lymph-vessels. 
The  disease  in  severe  cases  produces  enormous  swelling, 
areas  which  feel  boggy,  a  dusky- red  discoloration,  and  great 
burning  pain.  Gangrene  of  superficial  areas  is  not  unusual, 
due  to  thrombosis  of  vessels  or  coagulation -necrosis  from 
toxins.  The  discharges  of  the  wound,  if  a  wound  exists, 
are  apt  to  dry  up,  and  the  wound  becomes  foul,  dry,  and 
brown.  The  adjacent  lymphatic  glands  are  much  enlarged. 
The  disease  is  ushered  in  by  a  chill,  which  is  followed  by 
high  oscillating  temperature,  due  to  suppurative  fever, 
sapremia,  or  even  septic  infection  or  pyemia.  Sweats 
are  noted  during  falling  temperature.  Diffuse  suppuration 
tends  to  arise  in  infected  compound  fractures,  in  extrava- 
sation of  urine,  and  after  the  infliction  of  a  wound  upon 
a  person  broken  down  in  health.  It  is  not  unusual  after 
scarlet  fever,  and  is  typical  of  phlegmonous  erysipelas.  The 
pus  is  sanious  and  offensive,  and  burrows  widely  in  the 
subcutaneous  tissue  and  intermuscular  planes.  This  diffused 
suppuration  may  widely  separate  muscles,  and  even  lay  bare 
the  bones.  It  is  a  very  grave  condition,  and  may  cause 
death  by  exhaustion,  septic  intoxication,  septic  infection, 
pyemia,  or  hemorrhage  from  a  large  vessel  which  has  been 
corroded.  Cellulitis  of  a  mild  degree  may  surround  an  in- 
fected wound  or  a  stitch-abscess.  Its  spread  is  manifested 
by  red  Hnes  of  lymphangitis  running  up  to  the  adjacent 
lymphatic  glands.  Light  cases  may  not  suppurate,  the 
lymphatics  carrying  off  the  poison.     Any  case  of  cellulitis  is. 


ACUTE   ABSCESSES. 


123 


however,  a  menace,  and  any  severe  case  is  highly  dangerous 
(see  Erysipelas). 

Acute  Abscesses. — An  abscess  is  a  circumscribed  cavity 
of  new  formation  containing  pus.  We  emphasize  the  fact 
that  it  is  a  circu))iscribcd  cavity — circumscribed  by  a  mass 
of  leukocytes  and  proliferating  connective-tissue  cells.  A 
purulent  infiltration  is  not  circumscribed,  hence  it  does  not 
constitute  an  abscess.  An  essential  part  of  the  definition  is 
the  assertion  that  the  pus  is  in  a  cavity  of  nczv  formation,  in 
an  abnormal  cavity ;  hence  pus  in  a  natural  cavity  (pleural, 
pericardial,  synovial,  or  peritoneal),  constitutes  a  purulent 
effusion,  and  not  an  abscess  unless  it  is  encysted  in  these 
localities  by  walls  formed  of  inflammatory  tissue. 

An  acute  abscess  is  due  to  the  deposition  and  multiplica- 
tion of  pyogenic  bacteria  in  the  tissues  or  in  inflammatory 
exudates.  These  bacteria  attack  exudates  or  tissues,  form 
irritants  which  cause  inflammation  or  intensify  existing  in- 
flammation, and  by  exerting  a  peptonizing  action  on  inter- 


FlG.  40. — Infiltration  of  connective  tissue  of  cutis  (\ 

center  ^Senn). 


3)  with  beginning  suppuration  in  the 


cellular  substance  and  the  fibrin  of  the  exudate  liquefy  tis- 
sue and  the  products  of  inflammation,  and  form  pus.  As  a 
rule,  within  twent}^-four  hours  after  lodgement  of  the  bac- 
teria the  exudation  increases  in  amount,  the  migrated  leuko- 
cytes gather  in  enormous  numbers,  the  fibers  of  tissue  swell 
up,  and  the  connective-tissue  spaces  distend  with  cells  and 
fluid.  The  connective-tissue  cells,  acted  on  by  pus  cocci, 
multiply  by  kar}'okinesis,  develop  many  nuclei,  lose  their 
stellate'  projections,  degenerate,  and  constitute  one  form  of 


124 


SUPPURATION  AND  ABSCESS. 


pus-corpuscle,  leukocytes  forming  the  other.  All  the  small 
vessels  are  choked  with  leukocytes,  this  blocking  serving  to 
cut  off  nourishment  and  tending  to  produce  anemic  necrosis. 
Liquefaction  occurs  at  many  foci  of  the  inflammation,  drops 
of  pus  being  formed,  the  amount  of  each  being  progressively 
added  to  and  many  foci  coalescing  (Fig.  40).  The  pus- 
cavity  is  circumscribed,  not  by  a  secreting  pyogenic  mem- 
brane, but  by  a  mass  of  fibroblasts,  whose  cells  and  inter- 
cellular material  have  not  as  yet  broken  down  ;  such  a  mass 
of  fibroblasts  is  often  called  embryonic  tissue,  and  it  is  cir- 
cumscribed by  a  zone  of  inflammation  in  which  there  are 
hordes  of    migrated  leukocytes  (Fig.  41).     As  an  abscess 

increases  in  size  the  embry- 
onic tissue  from  within  out- 
ward liquefies  into  pus,  and 
the  zone  of  inflammation 
beyond  continually  enlarges 
and  forms  more  embryonic 
tissue.  After  a  time  the  in- 
flammation reaches  the  sur- 
face, the  embryonic  tissue 
glues  the  superficial  to  the 
deeper  parts,  the  superficial 
part  inflames  and  becomes 
embryonic  tissue,  the  inter- 
cellular substance  is  liquefied, 
a  small  elevation  due  to  fluid 
pressure  appears  (pointing), 
and  this  elevation  thins  and 
breaks  from  tension  and  liquefaction  (spontaneous  evacuation). 
When  an  abscess  forms  in  an  internal  organ  or  in  some  struct- 
ure which  is  not  loose,  like  connective  tissue — for  instance,  in 
a  lymphatic  gland — a  mass  of  pyogenic  bacteria,  floating  in 
the  blood  or  lymph,  lodges,  and  these  bacteria  by  means  of 
irritant  products  cause  coagulation-necrosis  of  the  adjacent 
tissue  and  inflamm.atory  exudation  around  it.  The  area  of 
coagulation-necrosis  becomes  filled  with  white  blood-cells, 
and  the  dry  necrosed  part  is  liquefied  by  the  cocci.  Suppu- 
ration in  dense  structures  causes  considerable  masses  of 
tissue  to  die  and  to  be  cast  off,  and  these  masses  float  in  the 
pus.  Death  of  a  mass  with  dissolution  of  its  elements  is 
necrosis,  or  inflammatory  gangrene.  Pus  travels  in  the  line 
of  least  resistance.  It  may  reach  a  free  surface,  or  may 
break  into  a  cavity  or  joint,  may  invade  bone  or  destroy  a 
vessel.     When  an  abscess  ceases  to  spread  or  is  evacuated, 


Fig.  41. — Diagram  of  an  abscess  :  A,  pus; 
B,  layer  of  fibroblasts ;  C,  tissue  infiltrated 
with  leukocytes  ;  D,  zone  of  stasis  ;  E,  zone 
of  active  hyperemia  ;  F,  healthy  tissue. 


FORMS   OF  ABSCESSES.  1 25 

the  cellular  tissue  forming  the  walls  becomes  vascularized 
(granulation-tissue).  An  abscess  heals  by  the  collapse  of  its 
walls  and  fusion  of  the  granulations  (union  by  third  inten- 
tion), or  by  granulation  (union  by  second  intention).  In 
either  case  granulation-tissue  is  ultimately  converted  into 
fibrous   or  scar-tissue. 

Forms  of  Abscesses. — The  following  are  the  various 
forms  of  abscesses  :  acute,  which  follows  an  acute  inflamma- 
tion ;  strumous,  cold,  lymphatic,  tubercular,  or  chronic  abscess 
is  due  to  tubercle,  and    does  not  contain   true  pus  unless 
there  is  secondary'  infection.     It  presents  no  signs  of  inflam- 
mation.    A  lymphatic  abscess  may  form  in  a  week  or  two, 
and  hence  is'  not  necessarily  chronic,  which  term  may  also 
be  used  to  mean  a  persistent  non-tubercular  abscess  ;  caseous 
or  cheesy  abscess,  a  cavit>'  containing  thick  cheesy  masses,  is 
due,    perhaps,    to    the    fatt\-    degeneration   of  inflammatory 
exudate    and    pus-corpuscles,  but    most   commonly  results 
from    the    caseation    of  a   tubercular    focus ;    circumscribed 
abscess  is  one  limited  by  embr^-onic  tissue ;  diffused  abscess 
is  an  unlimited  collection  of  pus,  in  reality  not  an  abscess, 
but  either  a  purulent  effusion  or  a  purulent  infiltration  ;  con- 
o-estive,  gravitative,  zvandering,  or  hypostatic  abscess  is  a  col- 
kction '  of  pus  or  tubercular  matter  which  travels  from  its 
formation-point  and  appears  at  some  distant  spot  (as  a  psoas 
abscess);  critical  ox  consecutive  abscess  is  one  which  arises 
during  an  acute  disease;  diathetic  abscess   is  due  to  a  diath- 
esis ;  embolic  abscess  is  due  to  an  infected  embolus  ;    tym- 
panitic or  emphysematous  abscess  is  one  which  contains  the 
gases  of  putrefaction ;  encysted  abscess,  in  which  pus  is  cir- 
cumscribed in  a  serous  cavit\^ ;  fecal  or  stercoraceous  abscess 
is  one  containing  feces  in  consequence  of  a  communication 
with  the  bowel ;  follicular  abscess  is  one  arising  in  a  follicle ; 
hematic  abscess,  one  arising  around   blood-clot,  as  a  sup- 
purating hematoma ;  ;y^^r^^7/^/ abscess,  which  appears  upon 
the  margin  of  the  anus  ;  pyemic  or  metastatic  abscess  is  the 
embolic^abscess  of  pyemia  ;  milk  abscess  is  an  abscess  of  the 
breast  in  a  nursing  woman  ;  ossifluent  abscess,  arising  from 
diseased  bone ;  psoas  or  tubercular  abscess,  arising  from  verte- 
bral caries,  the  matter  following  the  psoas  muscle  and  usually 
pointing  in  the  groin  ;  sympathetic  abscess,  arising  some  dis- 
tance from  the  exciting  cause,  such  as  a  suppurating  bubo 
from  chancroid,  is  not  in  realit}'  sympathetic,  because  infec- 
tive material  has  been  carried  from  the  primar\-  focus  ;  thecal 
abscess  is  suppuration  in  a  tendon-sheath  ;  tropical  abscess  is 
an  abscess  of  the  liver,  so  named  because  it  occurs  chiefly  m 


126  SUPPURATION  AND  ABSCESS. 

tropical  countries  :  it  usually  follows  dysentery ;  urinary 
abscess,  caused  by  extra vasated  urine ;  verminous  abscess, 
one  which  contains  intestinal  worms  and  communicates  with 
the  bowel ;  syphilitic  abscess,  which  occurs  in  the  bones 
during  tertiary  syphilis,  and  which  is  gummatous  and  not 
pyogenic ;  Brodic's  abscess  is  a  chronic  abscess  of  a  bone, 
most  common  in  the  head  of  the  tibia;  superficial  abscess, 
which  occurs  above  the  deep  fascia ;  deep  abscess,  occurring 
below  the  deep  fascia;  and  residual  or  /i^^^^'i' abscess,  a  re- 
currence of  active  changes,  it  may  be  after  years,  about  the 
residue  of  a  former  tubercular  abscess. 

Symptoms  of  Acute  Abscess. — In  an  acute  abscess,  as 
before  stated,  a  part  becomes  inflamed  and  embryonic  tissue 
forms ;  this  is  Hquefied  (as  above  noted)  and  pus  is  produced. 
If  the  abscess  is  in  the  brain,  in  the  tonsil,  or  in  the  neigh- 
borhood of  the  rectum  or  vermiform  appendix,  the  odor  of 
the  pus  is  apt  to  be  offensive.  An  acute  abscess  can  occur 
in  a  person  of  any  constitution. 

Local  Symptoms. — Locally  there  is  intensification  of  in- 
flammatory signs,  and  swelling  enormously  increases.  At 
first  the  area  is  hard,  but  afterward  becomes  soft  and  finally 
fluctuates.  The  discoloration  becomes  dusky.  The  pain 
becomes  throbbing  and  the  sense  of  tension  increases.  The 
pain  is  greater  the  more  dense  the  implicated  tissue  is  and 
the  greater  the  number  of  nerves  it  contains.  At  every  pulse- 
beat  the  tension  in  the  abscess  increases  temporarily,  and 
hence  the  pain  momentarily  increases.  Pain  is  increased  by 
a  dependent  position  of  the  part.  There  is  great  tenderness. 
The  pain  may  be  felt  at  the  seat  of  suppuration  or  may  be 
referred  to  some  distant  point.  Tenderness  is  located  at 
the  focus  of  disease.  The  cutaneous  surface  is  seen  to  be 
polished  and  edematous,  and  after  a  time  pointing  is  observed 
and  fluctuation  can  be  detected. 

Constitutional  Symptoms. — In  cases  of  small  collections 
of  pus  in  unimportant  structures  there  may  be  no  obvious 
constitutional  disturbance.  If  the  abscess  contains  much  pus 
or  affects  an  important  part,  disturbances  generally  appear, 
from  slight  rigors  or  moderate  fever  to  chills,  high  tempera- 
ture, and  drenching  sweats.  The  constitutional  condition 
typical  of  an  abscess  is  due  to  the  absorption  of  retained 
toxins,  and  is  known  as  "  suppurative  fever."  When  suppu- 
ration is  long  continued  there  exists  a  fever  which  is  markedly 
periodic :  the  temperature  rises  in  the  evening,  attaining  its 
highest  point  usually  between  4  and  8  p.  m.,  and  then  sinks 
to  normal  or  nearly  normal  in  the  early  morning  (from  4  to 


ACUTE  ABSCESSES  IN   VARIOUS  REGIONS.  12/ 

8  A.  M.).  When  the  temperature  begins  to  fall  profuse  per- 
spiration takes  place.  This  fever  is  known  as  "  hectic." 
Prolonged  suppuration  causes  albuminoid  changes  in  various 
organs,  notably  in  the  liver,  spleen,  and  kidneys. 

The  signs  and  symptoms  of  an  abscess  are  somewhat 
modified  by  location,  and  it  is  wise  to  discuss  acute  abscesses 
in  different  situations. 

Acute  Abscesses  in  Various  Regions. — Abscess  of  the 
brain  in  about  50  per  cent,  of  cases  results  from  suppurative 
disease  of  the  middle-ear.  In  abscess  of  a  silent  region  of  the 
brain  symptoms  may  long  be  entirely  absent.  The  usual 
symptoms  are  headache,  vomiting,  delirium,  drowsiness, 
optic  neuritis,  and  often  a  subnormal  temperature.  Local- 
izing symptoms  may  be  present.  In  but  few  cases  are  there 
fever  and  sweats.     In  extradural  abscess  there  is  fever. 

Appendiceal  or  appendicular  abscess  results  from  inflam- 
mation, usually  with  perforation  of  the  vermiform  appendix, 
plastic  peritonitis  circumscribing  the  pus.  If  the  pus  has 
been  formed  by  colon  bacilli  or  staphylococci,  it  will  prob- 
ably be  circumscribed  and  limited  by  cellular  exudate, 
which  glues  together  the  mesentery  and  coils  of  small  intes- 
tine. If  the  pus  has  been  formed  by  streptococci,  it  will 
probably  not  be  limited,  and  the  peritoneum  will  be  attacked 
by  diffuse  septic  peritonitis.  The  signs  of  appendicular 
abscess  are  pain,  tenderness,  muscular  rigidity,  the  existence 
of  a  mass,  dulness  on  percussion,  and  sometimes  fluctuation 
and  skin-edema  in  the  right  iliac  fossa,  fever,  vomiting,  some- 
times constipation,  and  sometimes  diarrhea. 

Abscess  of  the  liver  may  not  be  announced  by  symptoms 
until  rupture.  It  may  follow  dysentery,  may  be  a  result  of 
the  lodgement  of  infected  clots  from  the  hemorrhoidal  veins, 
may  follow  upon  the  infective  phlebitis  of  appendicitis,  may 
result  from  septic  cholangitis  or  suppuration  of  a  hydatid 
cyst.  We  usually  find  fever  of  an  intermittent  type,  profuse 
sweats,  pain  in  the  back,  the  shoulder,  or  the  right  hypo- 
chondraic  region,  enlargement  of  the  area  of  liver-dulness, 
also  hepatic  tenderness,  and  finally  constitutional  symptoms 
of  the  existence  of  pus.  Sometimes  there  are  fluctuation 
and  skin-edema  over  the  liver,  and  the  general  cutaneous 
surface  may  be  a  little  jaundiced.  The  symptoms  vary  as 
the  pus  invades  adjacent  organs.  Where  there  are  pain  on 
respiration  and  evidences  of  diaphragmatic  pleuritis  the  pus 
is  probably  breaking  into  the  pleural  sac. 

Subphre?nc  abscess  is  apt  to  begin  beneath  the  diaphragm, 
though  in  some  few  instances  the  pus  forms  above  this  mus- 


128  SUPPURATION  AND   ABSCESS. 

cle,  and  subsequently  gains  access  to  the  region  beneath, 
Such  an  abscess  may  contain  not  only  pus,  but  gas,  and  in 
some  cases  also  fluid  from  the  stomach  or  intestine.  It  may 
arise  after  perforation  of  the  bowel  or  stomach,  or  it  may 
result  from  Pott's  disease,  perinephric  abscess,  traumatism, 
abscess  of  the  liver,  kidney,  spleen,  or  pancreas,  empyema  or 
pneumonia  (Greig  Smith).  The  signs  are  pain,  fever,  sweats, 
dyspnea,  cough,  and  the  physical  signs  of  a  collection  of 
fluid  beneath  the  diaphragm  and  of  gas  in  the  cavity  of  the 
abscess. 

Abscess  of  the  lung  gives  the  physical  signs  of  a  cavity ; 
the  expectoration  is  offensive  and  contains  fragments  of  lung- 
tissue.  An  abscess  may  occasionally  be  located  by  the  use 
of  the  X-rays.  Pyemic  abscesses  may  exist  and  yet  escape 
discovery. 

Abscess  of  the  niediastiimiii  causes  throbbing  retrosternal 
pain,  chills,  fever,  sweats,  and  often  dyspnea.  A  tumor  may 
appear  which  pulsates  and  fluctuates,  but  the  pulsation  is  not 
expansile. 

Perinephric  abscess  usually  causes  tenderness  and  pain  in 
the  lumbar  region  or  about  the  hrp-joint,  which  pain  runs 
down  the  thigh  and  is  accompanied  by  retraction  of  the  tes- 
ticle. Induration,  fluctuation,  or  edema  of  the  skin  may  be 
observed  in  the  lumbar  region,  and  there  is  tenderness  in  the 
loin.  The  constitutional  symptoms  of  suppuration  usually 
exist. 

Abscess  of  the  antrum  of  Higliniore  causes  pain,  edema- 
tous swelling  of  the  bone,  and  crepitation  on  pressure  upon 
the  superior  maxillary  bone.  Pus  may  escape  from  the  nos- 
tril of  the  diseased  side  when  the  head  is  bent  in  the  direction 
of  the  healthy  side.  A  rhinoscopic  examination  discloses 
the  fluid  passing  into  the  nares.  The  antrum  on  the  side  of 
the  abscess  cannot  be  transilluminated  by  an  electric  light 
in  the  mouth  (Garel's  sign). 

Abscess  of  the  larynx  induces  violent  cough,  pain,  interfer- 
ence with  the  voice,  swallowing,  and  breathing,  and  can  be 
seen  with  a  laryngoscope. 

An  ischiorectal  abscess  is  situated  in  the  areolar  tissue  of 
the  ischiorectal  fossa.  The  pyogenic  organisms  usually  gain 
entrance  to  the  lymphatics  by  way  of  an  abrasion,  fissure,  or 
ulceration  of  the  rectum  or  anus.  In  rare  cases  they  reach 
the  fossa  in  the  blood-stream.  The  pain  is  severe  and  throb- 
bing ;  there  are  great  tenderness,  redness  and  edema  of 
skin,  induration,  and  usually  the  constitutional  symptoms  of 


DIAGXOSIS   OF  ABSCESS.  1 29 

pus  formation.  Fluctuation  is  a  ven'  late  sign  because  of  the 
density  of  the  fascia. 

Prostatic  abscess  is  manifested  by  chills,  fever,  sweats,  fre- 
quency of  micturition,  tenderness  of  the  perineum  and  rec- 
tum, and  agonizing  pain,  developing  during  an  attack  of 
acute  prostatitis. 

Abscess  of  the  breast  can  arise  from  absorption  of  pyogenic 
bacteria  from  a  fissure  or  abrasion  of  the  nipple.  Some  sur- 
geons maintain  that  the  bacteria  enter  along  the  milk-ducts, 
while  others  assert  that  they  gain  entrance  by  the  lymphatics. 
It  is  most  common  in  nursing  women.  Its  symptoms  are 
pulsatile  pain,  dusky  discoloration,  skin-edema,  fluctuation, 
and  usually  constitutional  disorder. 

Suppurative  thecitis  ox  felon  is  a  form  of  diffuse  suppuration 
(p.  623). 

Palmar  abscess  is  a  purulent  effusion  fp.  62 1 ). 

Furuncle  and  carbuncle  are  discussed  on  pages  916  and 

917- 

Empycjna  is  a  purulent  effusion  into  the  pleural  sac  (p.  724). 
It  is  technically  an  abscess  if  it  becomes  encapsuled. 

Diagnosis. — The  diagnosis  of  an  abscess  rests  upon — (i) 
its  histor}-;  (2)  fluctuation ;  (3)  pointing;  (4)  surface-edema; 
and  (5)  the  use  of  the  tubular  exploring-needle. 

Fluctuation  is  the  sensation  imparted  to  a  finger  held 
against  a  sac  containing  fluid  when  a  wave  is  started  in  the 
fluid  by  striking  the  mass  with  a  finger  of  the  other  hand. 
Fluctuation  cannot  be  obtained  if  the  amount  of  fluid  is  small. 
It  should  never  be  sought  for  across  a  limb,  but  rather 
along  it. 

A  suspected  abscess  in  a  part  containing  large  blood- 
vessels under  no  circumstance  should  be  opened  by  a 
bistoun,'  without  knowing  that  the  diagnosis  is  certainly  cor- 
rect. This  knowledge  is  obtained  in  some  cases  by  inserting 
a  small  aspirating-needle  and  obsen'ing  the  nature  of  the 
fluid  which  exudes.  An  abscess  which  moves  with  the  pulse 
because  it  rests  upon  an  artery  may  be  confounded  with  an 
aneur}^sm.  The  pulse-movements  of  such  an  abscess  are  in 
one  direction  only  ;  the  abscess  is  lifted  with  each  pulse-beat, 
but  does  not  enlarge,  and  if  a  finger  is  laid  upon  either  side  of 
it  the  fingers  will  be  lifted  but  not  separated.  The  pulse- 
movements  of  an  aneur^'sm  are  in  all  directions  ;  they  are 
expansile,  the  tumor  grows  larger,  and  the  fingers  Avill  not 
only  be  lifiied,  but  will  also  be  separated.  The  tubular  ex- 
ploring-needle can  be  used  in  doubtful  cases ;  if  aseptic,  it 
will  do  no  harm  even  to  an  aneur\^sm.  Many  able  surgeons 
9 


I30 


SUPPURATION  AND  ABSCESS. 


object  to  the  employment  of  a  grooved  exploring-needle,  on 
the  ground  that  when  plunged  into  infected  areas  and  with- 
drawn the  track  of  the  penetration  becomes  infected  by  the 
fluid  which  escapes.  A  rapidly  growing,  small-cell  sarcoma 
feels  not  unlike  an  abscess ;  but  the  exploring-needle  dis- 
covers blood,  and  not  pus.  A  cystic  tumor  is  separated 
from  an  abscess  by  the  absence  of  inflammation,  or,  if  it  in- 
flames, by  the  nature  of  the  contained  fluid.  Ordinary  cau- 
tion will  prevent  one  confounding  an  abscess  with  stran- 
gulated hernia.  A  tubercular  abscess  is  separated  from  an 
acute  abscess  by  the  absence  of  inflammatory  signs  in  the 
former.  The  contents  of  the  acute  abscess  differ  from  those 
of  the  chronic  abscess.  When  an  abscess  exists  in  an  im- 
portant region   (brain,   appendix,   liver,  etc.),  cultures  of  the 


Fig.  42. — Vischer's  case  for  carrying  culture-tubes  for  inoculation. 

pus  should  be  taken  after  incision.  Such  studies  often  give 
valuable  information  as  to  the  probable  course  of  the  condi- 
tion, and  an  accumulation  of  many  accurate  observations 
will  add  greatly  to  scientific  information.  Fig.  42  shows  a 
convenient  case  for  carrying  culture-tubes. 

Prognosis. — The  prognosis  varies  according  to  the  num- 
ber of  abscesses,  their  location  and  size,  the  strength  of  the 
patient,  and  the  virulence  of  the  causative  bacteria. 

Treatment. — In  the  treatment  of  an  abscess  there  is  one 
absolute  rule  which  knows  no  exception,  namely,  that  when- 
ever and  wherever  pus  is  found  the  abscess  should  be  evac- 
uated at  once,  and,  after  evacuating  it,  thorough  drainage  must 
be  provided  for.  It  should  be  opened  early,  if  possible  even 
before  pointing  or  fluctuation,  to  prevent  tissue-destruction, 
subfascial  burrowing,  and  general  contamination.     Drainage 


TREA  TMEXT  OF  ABSCESS.  I  3  I 

is  continued  until  the  discharge  becomes  scant)',  thin,  and 
seropurulent. 

Abscess  of  the  liver  requires  that  an  incision  be  made 
along  the  edge  of  the  ribs  down  to  the  liver,  which  organ 
is  then  stitched  to  the  edges  of  the  wound.  In  a  day  or 
two  after  the  first  operation  the  two  layers  of  peritoneum 
are  firmly  adherent  and  the  abscess  can  be  opened  without 
dano-er  of  the  passage  of  pus  into  the  peritoneal  cavit}'. 
The  abscess  is  opened  and  washed  out,  and  a  tube  inserted. 
Surgeons  occasionally  tr\-  to  locate  the  pus  by  the  use  of  an 
aspirator  before  doing  the  cutting  operation.  Abscess 
of  the  liver  is  occasionally  reached  by  resecting  a  rib,  open- 
ing the  pleural  sac,  and  incising  the  diaphragm  (transthoracic 
hepatotomy).  Abscess  of  the  mediastinum,  like  all  other 
abscesses,  requires  incision  and  drainage.  This  is  effected 
by  cutting  between  the  rib  cartilages  or  by  trephining  the 
sternum.  In  abscess  of  the  lung  an  incision  is  made  and  the 
pleura  is  exposed.  The  incision  is  usually  through  an  inter- 
costal space  :  but  if  the  spaces  are  narrow,  it  will  be  necessarv^ 
to  resect  a  rib.  If  the  two  layers  of  pleura  are  found  ad- 
herent, the  operation  is  proceeded  with.  If  they  are  not 
adherent,  they  are  stitched  together  with  r.  catgut  suture,  and 
the  surgeon  waits  48  hours  before  continuing.  The  operation 
is  completed  by  locating  the  pus  by  means  of  an  aspirator, 
evacuating  it  by  the  cauten.-  at  a  dull-red  heat,  and  insert- 
ing a  drainage-tube  into  the  abscess-cavitv'.  In  abscess  of 
the  antrnm  of  Highmore  bore  a  gimlet-hole  through  the 
superior  maxillan.-  bone,  above  the  canine  tooth,  or  perforate 
the  bone  by  means  of  a  trocar.  Irrigate  daily  with  boiled 
water  or  normal  salt  solution.  Keep  the  opening  from 
contracting  by  inserting  a  small  tent  of  iodoform  gauze. 
In  persistent  cases  it  may  be  necessar\'  to  draw  a  tooth, 
break  through  the  socket  into  the  antrum,  and  insert  a 
silver  or  hard-rubber  tube.  In  ven,'  persistent  cases  osteo- 
plastic resection  of  a  portion  of  the  upper  jaw  ^\-ill  be 
demanded.  In  appendicular  abscess  incise,  support  the 
abscess-walls  with  gauze,  remove  the  appendix  in  most 
cases,  but  not  in  all,  and  insert  a  drainage-tube  and  strands 
of  gauze 

An  ischiorectal  abscess  must  be  opened  early.  The  surgeon 
never  waits  for  fluctuation.  Fluctuation  is  a  ver\'  late  symp- 
tom. To  wait  for  it  entails  great  destruction  of  tissue  and 
serves  no  useful  purpose.  Place  the  patient  on  his  side,  with 
the  legs  drawn  up.  Insert  a  finger  in  the  rectum,  Hft  the 
abscess   toward  the  surface  and  incise  it  from  the  surface. 


132  SUPPURATION  AND  ABSCESS. 

The  incision  runs  from  the  anal  margin  Hke  a  spoke  from  the 
hub  of  a  wheel.  Irrigate  with  salt  solution,  inject  iodoform 
emulsion,  insert  a  drainage-tube,  dress,  and  let  the  patient 
know  he  is  in  danger  of  developing  a  fistula. 

In  abscess  of  the  breast  make  an  incision  radiating  from 
the  nipple,  or,  what  is  better,  incise  under  the  breast  by 
means  of  a  cut  at  the  inferior  thoracic  mammary  junction,  and 
enter  the  abscess  from  beneath.  In  abscess  of  the  brain  the 
skull  should  be  trephined,  the  membranes  incised,  and  the 
abscess  sought  for,  opened,  and  drained  (p.  6^/).  In  an  ordi- 
nary superficial  abscess,  after  cleansing  the  parts,  make  the 
skin  tense,  and  incise  with  a  sharp-pointed  curved  bistoury  at 
the  most  dependent  part  of  the  abscess.  Permit  the  pus  to 
run  out  itself;  pressure,  as  a  rule,  is  undesirable.  If  tissue- 
shreds  block  the  opening,  they  must  be  picked  out  with 
forceps.  If  the  atmospheric  pressure  will  not  cause  the  pus 
to  flow  out,  make  light  pressure  with  warm,  moist,  aseptic 
sponges.  After  the  pus  has  come  away  wash  the  cavity 
with  normal  salt  solution  or  boiled  water,  and  drain  with  a 
tube  for  two  or  three  days,  when  the  discharge  becomes  serous. 
Pursue  rigid  antisepsis  in  dealing  with  purulent  areas.  It  is 
true  we  already  have  infection  with  pyogenic  bacteria,  but 
infection  can  also  take  place  with  organisms  of  putrefaction, 
causing  pus  to  become  putrid,  or  with  other  bacteria,  for  in- 
stance, those  of  tetanus.  It  is  not  desirable  to  overdistend 
the  abscess-cavity  with  fluid,  because  the  hydrostatic  pressure 
might  break  down  the  wall  of  young  cells  and  infection  be 
diffused.  Do  not  irrigate  with  powerful  disinfectants.  They 
cannot  be  used  strong  enough  to  really  disinfect,  but  may 
easily  be  used  strong  enough  to  cause  necrosis  of  an  abscess- 
wall.  Peroxid  of  hydrogen  is  not  to  be  used  unless  the  in- 
cision is  large.  If  an  abscess  contains  putrid  pus,  after 
evacuation  irrigate  with  hot  salt  solution  or  peroxid  of  hydro- 
gen and  inject  iodoform  emulsion.  If  a  tube  is  not  used  and  the 
cavity  is  packed  with  iodoform  gauze,  remember  that  gauze 
will  not  drain  pus  and  requires  to  be  changed  once  a  day. 
An  abscess  should  be  dressed  with  hot,  moist  antiseptic  dress- 
ings (antiseptic  fomentation).  When  the  discharge  becomes 
thin  and  scanty,  dry  aseptic  or  antiseptic  dressings  are  used. 

In  a  deep  abscess  or  an  abscess  situated  near  important 
vessels,  do  not  boldly  plunge  in  a  knife.  Hilton  says  to 
"  plunge  in  a  knife  is  not  courageous,  as  it  is  without  danger 
to  the  surgeon,  but  may  be  fatal  to  the  patient."  Remember 
also  that  a  large  amount  of  pus  displaces  normal  anatomical 
relations.     Hilton's  method  of  opening  a  deep  abscess  (as  in 


TREATMENT  OF  ABSCESS. 


133 


the  axilla  or  neck)  is  to  cut  to  the  deep  fascia,  nick  the  fascia 
with  a  knife,  and  then  push  into  the  abscess  a  grooved  director 
until  pus  shows  in  the  groove ;  along  the  groove  push  a  pair 
of  closed  dressing-forceps  ;  after  they  reach  the  depths  open 
them  and  withdraw  them  while  open,  and  so  dilate  the  open- 
ing ;  then  insert  a  tube  and  irrigate.  In  an  abscess  in  the 
posterior  part  of  the  orbit,  after  incising  transversely  a  por- 
tion of  the  upper  lid,  the  abscess  should  be  reached  by  this 
method.  Always  endeavor  to  open  an  abscess  at  its  most 
dependent  part,  remembering  that  the  situation  of  this  part 
may  depend  upon  whether  the  patient  is  erect  or  recumbent. 
If  we  do  not  make  the  opening  at  the  lowest  point,  all  the 
pus  will  not  run  out  and  the  walls  will  not  completely  col- 
lapse. A  deep  abscess  must  be  drained  thoroughly  until  the 
discharge  becomes  seropurulent.  When  the  tube  is  removed 
it  is  wise  to  insert  a  tent  of  iodoform  gauze  just  through  the 
outlet  of  the  abscess.  This  tent  prevents  the  skin  from  clos- 
ing over  the  channel.  It  is  removed  and  a  new  one  is  inserted 
every  day  until  it  is  clear  that  there  is  no  longer  danger  of 
fluid  becoming  blocked  and  retained.  When  an  abscess  con- 
tains diverticula  or  pouches  they  should  be  slit  up  or  a  counter- 
opening  ought  to  be  made.  A  counter-opening  is  made  by 
entering  the  dressing-forceps  at  the  first  incision,  pushing 
them  through  the  abscess  to  the  point  where  we  wish  to 
make  our  counter-opening,  opening  the  blades,  and  cutting 
between  them  from  without  inward.  The  blades  are  then 
closed  and  projected  through  the  incision ;  they  are  opened 
to  dilate  the  new  door,  and  closed  again  upon  a  drainage- 
tube,  which  is  pulled  through  from  opening  to  opening  as 
the  instrument  is  withdrawn.  When  pus  burrows,  insert  a 
grooved  director  in  each  channel  and  slit  the  sinus  with  a 
knife.  An  abscess  may  make  an  opening  through  dense 
fascia,  the  opening  being  small  like  the  neck  of  an  hour-glass 
(shirt-stud  abscess).  Always  examine  to  see  if  such  a  con- 
dition exists,  and  if  it  is  found,  incise  the  fascia. 

In  a  deep  abscess  in  which  the  pus  is  putrid  frequent 
irrigation  is  desirable.  In  such  a  case  two  tubes  may  be  em- 
ployed (Fig.  43).  The  tubes  are  prevented  from  slipping  in 
by  the  use  of  a  safety-pin.  The  irrigating  fluid  is  passed 
into  the  cavity  {d)  through  the  tube  b,  and  it  runs  out  through 
the  tube  c. 

Rest  is  of  the  first  importance  in  the  healing  of  an  abscess, 
and  we  try  to  obtain  it  by  bandages,  splints,  and  pressure, 
which  will  immobilize  adjacent  muscles  and  approximate 
the  abscess-walls.     If  an  abscess  is  slow  to  heal,  use  as  a 


134 


SUPPURATION  AND  ABSCESS. 


daily  injection  a  solution  of  corrosive  sublimate  of  the 
strength  of  i  :  lOOO,  or  3  drops  of  nitric  acid  to  5]  of  water, 
or  3  grains  of  zinc  sulphate  to  5j  of  water,  or  a  5  per  cent, 
solution  of  carbolic  acid,  or  a  2  per  cent,  aqueous  solution 
of  pyoktanin,  or  20  drops  of  tincture  of  iodin  to  sj  of  water, 
or  a  solution  of  bichlorid  of  palladium.  Peroxid  of  hydrogen 
is  a  dangerous  agent  to  inject  into  the  cavity  of  a  deep 
abscess  of  the  neck,  as  the  liberated  gas  may  not  escape  from 


Fig.  43. — Drainage-tubes  for  abscess  requiring  irrigation. 


the  opening,  but  may  pass  widely  into  the  tissues  and  cause 
great  distention.  The  author  saw  a  child  who  narrowly 
escaped  death  after  such  an  injection.  In  this  patient  the  gas 
passed  beneath  the  pharyngeal  mucous  membrane  and  the 
swelling  almost  occluded  the  air-passages.  The  constitu- 
tional treatment  of  an  abscess  depends  upon  its  severity  and 
upon  the  importance  of  the  structures  involved.  In  a  bad 
case  the  patient  should  be  put  to  bed,  opiates  given  with  a 
free  hand,  the  bowels  kept  active  by  calomel  and  salines, 
skin-activity  maintained,  nutritious  food  insisted  on,  and 
stimulants  hberally  employed. 

Purulent  Effusions. — (See  Suppurative  Thecitls,  Palmar  Ab- 
scess, Suppurative  Synovitis,  Purulent  Peritonitis,  Empyema, 
etc.). 

Tubercular  abscess,  called  also  chronic,  cold,  scrofu- 
lous, and  lymphatic,  is  an  area  of  disease  produced  by  the 
action  of  the  bacilli  of  tubercle  and  circumscribed  by  a  dis- 
tinct membrane.  Ashhurst  says  that  the  term  "  chronic  "  is 
a  bad  one.  "  It  refers  etymologically  only  to  time.  A 
phlegmonous  abscess,  if  deeply  seated,  may  be  of  slower 
development  than  a  chronic  or  cold  abscess  which  is  super- 
ficial." A  tubercular  abscess  is  most  common  in  connection 
with  tubercular  disease  of  the  lymphatic  glands,  bones, 
joints,  and  subcutaneous  connective  tissues,  and  is  rare  after 
the  twentieth  year.  It  may  contain  quarts  of  curdy  pus. 
The  bacilli  of  tubercle  cause  inflammation,  and  granulation- 


TUBERCULAR  ABSCESS.  1 35 

tissue  is  formed,  which  in  the  center  undergoes  coagulation- 
necrosis  and  caseation,  and  at  the  periphery  is  converted  into 
fibrous  tissue  containing  tubercles.  The  mass  of  granula- 
tion-tissue undergoes  necrosis  in  the  center,  chiefly  because 
of  the  direct  action  of  the  toxins  and  partly  because  the 
capillaries  are  gradually  lessened  in  caliber.  The  necrotic 
mass  undergoes  fatty  degeneration  (caseation).  If  caseated 
tubercular  granulation-tissue  liquefies,  scrofulous,  curdy,  or 
tubercular  pus  is  formed,  and  the  growing  collection  of 
fluid  is  called  a  tubercular  or  cold  abscess.    Such  an  abscess 

.does  not  contain  true  pus.     The  tubercle  bacillus  is  .not_a. 
pyogenic   organism.     If  true  pus   forms,  it   is  because  of  a 

"secondary  infection  with  pus-cocci — an  accident,  and  not  a 
part  of  the  natural  process  of  formation  of  a  cold  abscess. 
A  cold  abscess  is  filled  with  liquefied  caseated  tubercle, 
masses  of  coagulated  fibrin,  and  bits  of  necrotic  tissue.  The 
wati— ©f"arT:TJlcr~abscess  consists  of  granulation-tissue  and 
fibrous  tissue,  the  granulation-tissue  being  in  the  interior. 
The  yellowish  granulation-tissue  lining  a  cold  abscess  is 
filled  with  miliary  tubercles,  and  is  called  Volkmann's  mem-  - 
brane.  The  fibrous  wall  was  formerly  called  the  pyogenic 
membrane,  because  of  the  mistaken  notion  that  it  secreted 
pufulent  material.  A  cold  abscess  jiiay;..be  absorbed  or 
m.ay  become  encapsuled  by  densely  fibrous  organization  of 
its  limiting  wall.  It  may  enlarge  greatly  and  involve  various 
tissues.  Tubercular  matter  rarely  invades  a  muscle,  whereas 
syphilis  often  attacks  muscle  (Warren). 

Symptoms. — The  term  cold  abscess  is  employed  for  a 
tubercular  abscess  because  it  presents  no  inflammatory  signs. 
There  is  no  local  heat ;  no  discoloration  unless  pointing 
occurs ;  the  parts  look  paler  than  natural ;  pain  is  absent  in 
the  abscess,  though  it  may  exist  at  the  point  of  origin  of  the 
fluid.  The  tubercular  material  often  wanders  from  its  point 
of  origin  under  the  influence  of  gravity.  Fluctuation  is  present 
unless  thick  walls  mask  it.  Constitutional  symptoms  are 
trivial  or  absent  unless  secondary  infection  occurs.  The 
swelling  may  suddenly  appear  in  some  spot — the  groin,  for 
instance.  When  it  appears  suddenly  it  has  travelled  from  a 
distant  and  older  area  of  disease.  The  abscess  may  last  for 
years  without  producing  pain  or  annoyance.  The  introduc- 
tion of  a  tubuEr  exploring-needle  will  settle  the  diagnosis. 
The  constitution  is  invariably  below  normal  because  of  the 
tubercular  infection,  and  the  temperature  may  be  a  little 
above  normal.  A  cold  abscess  which  is  infected  with  putre- 
factive or  pyogenic  organisms  exhibits  great  inflammation, 


136  SUPPURATION  AND  ABSCESS. 

and  sapremia  or  septicemia  rapidly  develops.  In  tubercular 
disease  of  the  vertebrae  the  fluid  may  find  its  way  to  the  lum- 
bar region,  to  the  iliac  region,  or  to  the  immediate  neigh- 
borhood of  Poupart's  ligament,  above  or  below  it. 

Tubercular  Abscesses  in  Various  Regions.— Tu- 
bercular abscess  of  the  head  of  a  bone  (Brodie's  abscess) 
arises  in  the  cancellous  structure  of  a  long  bone,  most  often 
in  the  head  of  the  tibia.  Pain  is  continued  but  not  usually 
very  severe,  is  of  a  boring  character,  and  is  worse  when  the 
patient  is  in  bed.  Attacks  of  synovitis  arise  from  time  to  time 
in  the  adjacent  joint.  There  is  no  such  thing  as  an  acute  ab- 
scess_of,bj3^ne.  A  pyogenic  inflammation  of  such  "severity 
uiat  it  would  cause  an  acute  abscess  in  soft  parts,  in  bone 
causes  acute  necrosis.  The  tubercular  organisms  obtain 
access  to  the  bone  by  means  of  the  blood,  and  find  in  the 
bone  a  point  of  least  resistance. 

Retropharyngeal  or  postpharyngeal  abscess  is,  as  a  rule, 
but  not  always,  tubercular.  Such  an  abscess  is  usually 
due  to  caries  of  the  cervical  vertebrae,  but  can  arise  in  the 
connective  tissue  of  the  parts  or  as  a  tubercular  adenitis. 
An  abrasion  of  the  mucous  membrane  may  admit  the  bacilli  to 
the  connective-tissue  or  the  glands.  A  swelling  projects  from 
the  posterior  pharyngeal  wall,  and  there  is  great  interference 
with  respiration  and  deglutition.  Caseous  matter  from  caries 
of  the  cervical  vertebrae  may  reach  the  posterior  mediastinum 
by  following  the  esophagus,  or  it  may  appear  in  front  of  or 
behind  the  sternomastoid  muscle  (Edmund  Owen). 

Dorsal  Abscess. — The  tubercular  matter  in  dorsal  ab- 
scess arises  from  dorsal  caries,  flows  into  the  posterior  medi- 
astinum, and  reaches  the  surface  by  passing  between  the 
transverse  processes.  The  tubercular  matter  from  dorsal 
caries  may  run  forward  between  the  intercostal  muscles  or 
between  these  muscles  and  the  pleura,  pointing  in  an  inter- 
costal space  at  the  side  of  the  sternum  or  by  the  rectus 
muscle.  It  may  open  into  the  gullet,  windpipe,  bronchus, 
pleural  sac,  or  pericardium.  It  may  descend  to  the  dia- 
phragm and  travel  under  the  inner  arcuate  ligament  to  form 
a  psoas  abscess,  or  under  the  outer  arcuate  ligament  to  form 
a  lumbar  abscess.  A  psoas  abscess  points  external  to  the 
femoral  vessels,  a  characteristic  which  distinguishes  it  at  once 
from  a  femoral  hernia. 

Iliac  abscess  arises  from  lumbar  caries,  the  swelling  lying 
in  the  iliac  fossa  and  pointing  above  Poupart's  ligament. 

Psoas  abscess  is  usually  due  to  lumbar  caries,  but  may 
arise  from  dorsal  caries.     The  fluid  usually  points  in  Scarpa's 


TUBERCULAR   ABSCESS. 


137 


triangle  external  to  the    femoral  vessels,  but  may  descend 
much  lower  (Fig.  44).    A  psoas  or  iliac  abscess,  by  following 
the  lumbosacral  cord  and  great  sciatic  nerve,  forms  a  gluteal 
abscess.   These  abscesses  may 
open  into  the  bowel,  bladder, 
ureter,  or  peritoneal  cavity. 

Lumbar  Abscess. —  In  a 
lumbar  abscess  the' fluid  pro- 
duced by  dorsal  caries  de- 
scends beneath  the  outer  arcu- 
ate ligament,  or  the  fluid  from 
lumbar  caries  which  collected 
anterior  to  or  in  the  quadratus 
lumborum  muscle  passes  be- 
tween the  last  rib  and  iliac 
crest  in  the  triangle  of  Petit, 
the  small  space  bounded  b)^ 
the  crest  of  the  ilium,  the  pos- 
terior edge  of  the  external  ob- 
lique muscle,  and  the  anterior 
edge  of  the  latissimus  dorsi 
muscle.^ 

Chronic  abscess  of  the 
breast  is  a  caseated  area  of 
tuberculosis     of    the    breast. 

A  lump  is  detected,  which  slowly  enlarges  and  finally  rupt- 
ures, sinuses  being  formed.  The  axillary  glands  are  apt  to 
be  implicated.  The  patient  belongs  to  a  tubercular  stock, 
as  a  rule  gives  a  history  of  previous  tubercular  troubles  of 
various  sorts,  and  has  usually  borne  children.  Chronic 
abscess  of  the  breast  causes  little  or  no  pain. 

Treatment  of .  Tubercular  Abscess. — If  a  small  cold  ab- 
scess exists  in  a  superficial  structure,  open  it  with  aseptic 
care,  rub  its  walls  with  bits  of  gauze  to  remove  tubercular 
masses,  irrigate  with  i  :  looo  mercurial  solution,  inject  with 
iodoform  emulsion,  pack  with  iodoform  gauze,  and  dress  anti- 
septically.  When  the  discharge  becomes  thin  and  scanty 
the  packing  can  be  dispensed  with.  If  it  be  slow  in  healing, 
inject  or  swab  out  with  a  stimulating  fluid  as  in  acute 
abscess,  or  inject  with  iodoform  emulsion. 

Chronic  Abscess  of  Bone. — Make  an  incision  to  bare  the 
bone.  Open  the  abscess  with  the  trephine,  the  gouge,  or 
the  chisel ;  curet  with  a  sharp  spoon  and  gouge ;  cut  away 

1  For  a  lucid  description  of  these  abscesses  see  Owen's  Manual  of  Anatomy, 
from  wliich  much  of  the  above  is  condensed. 


Fig.  44. — Psoas  abscess  (Albert 


138  SUPPURATION  AND  ABSCESS. 

the  edges  of  the  bone  with  rongeur  forceps  ;  irrigate  the  cavity 
with  hot  corrosive  sublimate  solution  (i  :  lOOO),  dry  its  walls 
with  gauze,  and  paint  the  cavity  with  pure  carbolic  acid  ;  pack 
with  iodoform  gauze  and  apply  antiseptic  dressings.  It  is  bet- 
ter not  to  employ  an  Esmarch  apparatus.  Bleeding  will  not 
be  severe,  and  when  no  apparatus  is  used  one  can  be  sure  that 
all  the  diseased  bone  has  been  removed,  because  sound  bone 
bleeds  and  dead  bone  does  not. 

Cold  Abscess  of  Lymphatic  Glands. — In  non-exposed 
portions  of  the  body  the  capsule  of  the  gland  should  be 
incised  and  dissected  or  scraped  away,  and  the  cavity 
swabbed  out  with  pure  carbolic  acid  and  packed  with  iodo- 
form gauze.  If  the  abscess  is  allowed  to  burst,  it  will  cause 
an  ugly  scar ;  therefore  in  exposed  portions  of  the  body  an 
effort  should  be  made  to  prevent  a  scar  by  incising  early 
before  the  skin  is  involved.  When  only  a  little  caseated 
matter  exists  and  the  skin  is  not  discolored,  prepare  the 
parts  antiseptically,  incise,  rub  the  interior  with  gauze,  inject 
iodoform  emulsion,  use  a  small  drainage-tube,  and  suture  the 
wound.  It  used  to  be  a  custom  in  such  cases  to  carry  a  silk 
thread  by  means  of  a  needle  through  the  skin,  through  the 
gland,  and  out  at  its  lowest  point,  the  part  being  then  dressed 
with  gauze.  In  three  days  the  thread  was  removed  and  a 
firm  compress  was  applied.  The  plan  is  not  satisfactory  and 
incision  is  to  be  preferred.  When  the  gland  is  almost 
entirely  broken  down  and  the  skin  above  it  is  purple 
and  thin,  insert  a  hypodermatic  needle  through  sound  skin 
into  the  abscess,  draw  off  the  pus,  and  inject  iodoform  emul- 
sion (10  per  cent,  of  iodoform,  90  per  cent,  of  glycerin  or 
olive  oil).  This  procedure  is  to  be  repeated  when  pus  again 
accumulates.  By  this  means  we  can  sometimes  effect  a  cure 
in  a  week  or  so.  When  an  abscess  breaks  or  is  at  the  point 
of  breaking  cut  away  all  purple  skin,  curet  the  abscess- 
walls  (the  abscess  having  become  a  tubercular  ulcer), 
remove  the  remains  of  gland  and  capsule,  swab  the  cavity 
with  pure  carbolic  acid,  and  dress  with  iodoform  and  anti- 
septic gauze. 

Tubercular  glands  ought  to  be  extirpated  before  they 
caseate  and  form  an  abscess. 

Cold  Abscess  of  Maminary  Gland. — Many  operators 
simply  incise,  curet,  pack  with  iodoform  gauze,  and  dress 
antiseptically.  It  is  wiser  to  remove  the  entire  gland,  and 
to  clean  out  the  axilla,  as  in  an  operation  for  cancer,  in  order 
to  prevent  bdlh  recurrence  and  dissemination. 

Large  Cold  Abscesses  (Psoas  Abscess). — In  view  of  the 


TUBERCULAR  ABSCESS.  I  39 

facts  that  these  abscesses  may  cause  no  trouble  for  years 
and  that  an  operation  may  be  fatal,  some  eminent  surgeons 
are  opposed  to  an  operation  unless  the  abscess  is  moving 
toward  inevitable  rupture  or  is  disturbing  the  functions  of 
organs  by  pressure.  Most  practitioners  believe,  however, 
that  this  mass  of  tubercular  matter  is  a  source  of  danger 
through  being  a  depot  of  infective  organisms  which  may 
overwhelm  the  system,  and  that  death  will  rarely  occur  in 
the  hands  of  the  operator  who  employs  with  intelligence 
strict  antisepsis.  In  no  other  cases  is  attention  to  every 
detail  more  important,  as  a  mixed  infection  can  easily  take 
place,  and  will  probably  mean  death. 

In  many  cases  aspiration  can  be  employed  to  empty  the 
cavity,  injecting  either  a  10  per  cent,  iodoform  emulsion  to 
the  amount  of  giij,  or  giij  of  a  5  per  cent,  ethereal  solution 
of  iodoform  after  the  tubercular  fluid  has  been  sucked  out. 
After  injecting  the  emulsion  squeeze  and  manipulate  the  fluid 
into  every  nook  and  cranny.  The  American  Text-book  of 
Surgery  advises  the  injection  of  from  i  to  3  ounces  of  the 
following  preparation:  iodoform,  10  parts;  glycerin,  20; 
mucil.  gum  Arab.,  5  ;  carbolic  acid,  i  ;  water,  100. 

Whatever  fluid  is  chosen,  the  operation  must  be  repeated 
three  or  four  times  at  intervals  of  four  weeks.  It  is  danger- 
ous to  inject  large  amounts  of  iodoform,  as  poisoning  may 
be  produced  (p.  29).  Some  surgeons  incise  such  an  abscess, 
inject  iodoform  emulsion,  and  sew  up  without  drainage. 
Such  a  procedure  may  succeed,  may  fail,  and  is  sometimes 
followed  by  iodoform-poisoning.  If  aspiration  and  injection 
fail,  open,  under  rigid  antisepsis,  the  most  dependent  portion 
of  the  abscess,  scrape  its  wall  with  bits  of  gauze,  and  over- 
distend  with  a  I  :  1000  solution  of  warm  corrosive  sublimate. 
Let  the  mercurial  solution  run  out  and  then  irrigate  the 
cavity  with  hot  normal  salt  solution,  which  will  remove  the 
remains  of  the  corrosive  fluid.  With  a  long  probe  find  the 
highest  point  of  the  cavity,  and  make  a  counter-opening ; 
scrape  well.  It  is  useless  to  remove  carious  vertebrae.  Flush 
the  whole  area  with  corrosive  sublimate,  wash  out  the  mer- 
curial solution  with  hot  normal  salt  solution,  inject  emul- 
sion of  iodoform,  and  either  make  tube-drainage  from  open- 
ing to  counter-opening  and  from  bone  to  counter-openmg, 
or  pack  the  entire  cavity  with  iodoform  gauze.  If  hemor- 
rhage is  severe,  after  injecting  with  hot  salt  solution  the 
cavity  must  be  packed.  When  a  large  abscess  breaks  of 
itself,  it  should  at  once  be  drained  and  asepticized  as  above. 
In  the  treatment  of  a  cold  abscess  give  nutritious  food,  cod- 


I40  ULCERATION  AND  FISTULA. 

liver  oil,  quinin,  iron,  and  the  mineral  acids.  Removal  to 
the  seaside  is  often  indicated,  and  mechanical  appliances 
may  be  needed  for  diseases  of  the  bones  and  joints.  If 
secondary  infection  does  occur,  the  patient  develops  septic 
fever  and  almost  certainly  dies  {g.  z'.). 

Dorsal  abscess  and  lumbar  abscess  are  treated  after  the 
same  plan  as  psoas  abscess,  although  one  incision  only  is 
usually  necessary  unless  the  fluid  has  travelled  to  a  distant 
point. 

A  postpharyngeal  abscess  must  not  be  opened  through 
the  mouth.  To  open  it  in  this  manner  puts  the  patient  in 
danger  of  suffocation  by  fluid  running  into  the  larynx  during 
or  after  the  operation.  Further,  mixed  infection  of  the 
abscess-area  will  be  certain  to  ensue.  Septic  pneumonia 
will  be  apt  to  arise  from  inhaled  infected  particles,  and  pro- 
found gastro-intestinal  disturbance  will  be  liable  to  develop 
because  of  the  inevitable  swallowing  of  purulent,  putrid,  and 
tubercular  masses.  Incise  the  neck  and  open  into  the  abscess 
by  Hilton's  method,  going  through  the  sternocleidomastoid 
muscle  or  behind  it.  Rub  the  wall  of  the  abscess  with  bits  of 
gauze,  remove  any  loose  bone,  irrigate  with  hot  normal  salt 
solution,  inject  iodoform  emulsion,  insert  a  tube  or  pack 
with  iodoform  gauze. 

VII.  ULCERATION  AND  FISTULA. 

An  ulcer  is  a  loss  of  substance  due  to  molecular  death 
of  a  superficial  structure.  The  molecular  death  is  brought 
about  by  bacteria.  Ordinary  ulcers  are  caused  by  pus 
organisms.  The  action  of  the  pus  organisms  is  the  same  as 
in  an  abscess.  A  broken  abscess  becomes  an  ulcer,  and  an 
ulcer  is  in  structure  a  half-section  of  an  abscess.  The 
floor  of  an  ulcer  consists  of  granulation-tissue  and  cor- 
responds with  the  abscess-wall.  An  abscess  arises  from 
molecular  death  within  the  tissues  ;  an  ulcer,  from  molecu- 
lar death  of  a  free  surface.  An  ulcer  may  increase  in  size 
by  molecular  death  of  adjacent  structures  or  by  sloughing, 
that  is  to  say,  by  death  of  visible  masses  of  tissue.  A 
wound  healing  by  granulation  is  often  wrongly  called  an 
ulcer.  An  ulcer  must  not  be  confounded  with  an  excori- 
ation. In  an  ulcer  the  corium  is  always,  and  the  subcu- 
taneous tissue  is  generally,  destro3'ed,  and  a  scar  is  left 
after  healing.  In  an  excoriation  the  mucous  layer  of  epithe- 
lium is  exposed,  or  this  is  destroyed  and  the  corium  exposed. 
In  an  excoriation  the  corium  is  never  destroyed,  and  no  scar 


ACUTE    OR   IXFLAMED    ULCER    OF   THE   LEG.         14I 

remains  after  healing.  An  ulcer  heals  by  granulation  (p. 
109).  Embryonic  tissue  by  vascularization  becomes  granula- 
tion-tissue, granulation-tissue  is  converted  into  fibrous  tissue, 
the  fibrous  tissue  contracts,  and  by  pulling  the  edges  of  the 
ulcer  toward  each  other  lessens  the  size  of  the  cavity.  When 
the  granulations  reach  the  level  of  the  skin  the  epithelium  at 
the  edges  of  the  ulcer  proliferates  and  the  sore  is  soon 
co\-ered  over  with  new  epithelium. 

Necrosis  of  a  superficial  part  may  arise  from — (i)  In- 
flammation. The  pressure  of  the  exudate  can  cut  off  the 
circulation,  or  bacteria  may  directly  destroy  tissue.  Suppu- 
ration occurs.  (2)  The  action  of  pus  bacteria,  causing  pri- 
mary cell-necrosis.  (3)  Bacteria  of  putrefaction  and  organisms 
of  suppuration  acting  upon  a  wound.  (4)  Traumatism  or 
irritants,  producing  at  once  stasis,  which  is  added  to  by 
secondary  inflammation,  the  exudate  undergoing  purulent 
Hquefaction.  (5)  Prolonged  pressure.  (6)  Deficient  blood- 
supply.  (7)  Faulty  venous  return.  (8)  Degeneration  of  a 
neoplastic  infiltration  (gummatous,  malignant,  or  tubercular). 
(9)  Trophic  disturbance.  (10)  Nutritional  disturbances  (as 
scurvy).  Most  ulcers  are  due  to  pus  organisms,  and  even 
areas  of  necrosis  that  arise  from  something  else  (as  gumma- 
tous degeneration)  are  likely  to  suppurate. 

Classification. — Ulcers  are  classified  into  groups  ac- 
cording to  the  condition  of  the  ulcer  and  the  associated 
constitutional  state.  In  the  first  group  we  find  the  varicose, 
hemorrhagic,  acute,  chronic,  irritable,  neuralgic,  etc.  In  the 
second  group  are  placed  the  tubercular,  syphilitic,  senile, 
scorbutic,  etc.  All  ulcers,  whatever  their  origin,  are  either 
acute  or  chronic,  and  such  conditions  as  great  pain,  hemor- 
rhage, edema,  exuberant  granulations,  phagedena,  slough- 
ing, eczema,  gout,  syphilis,  scurvy,  etc.,  are  to  be  looked  upon 
as  complications.  The  leg  is  so  common  a  site  of  ulcers  as 
to  warrant  a  special  description  of  ulcers  of  this  part.  In 
describing  an  ulcer  state  the  patient's  previous  history ;  the 
supposed  cause;  the  situation;  the  outline;  the  duration; 
and  the  mode  of  onset  of  the  ulcer.  State  if  the  ulcer  is 
single  or  if  multiple  sores  exist,  and  if  there  is  or  is  not  pain. 
Whether  or  not  any  healing  has  ever  occurred,  and  the  pa- 
tient's constitutional  condition.  Set  forth  the  complications  ; 
the  state  of  anatomically  related  glands  ;  the  condition  of  the 
edge,  the  floor,  and  the  parts  about  the  ulcer,  and  the  nature 
and  quantity  of  the  discharge. 

Acute  or  inflamed  ulcer  of  the  leg  may  follow  an 
acute  inflammation  and  may  be  acute  from  the  start,  or  may 


142  ULCERATION  AND  FISTULA. 

be  first  chronic  and  then  become  acute.  It  is  especially- 
common  in  drunkards  and  among  those  of  dilapidated  con- 
stitutions. It  is  characterized  by  rapid  progress  and  intense 
inflammation.  There  is  rarely  more  than  one  ulcer.  In  out- 
line these  ulcers  are  usually  oval,  but  may  be  irregular.  The 
floor  of  an  acute  ulcer  contains  no  granulations,  but  is  com- 
posed of  the  raw  and  inflamed  tissues,  or  is  covered  with  a 
mass  of  gray  aplastic  lymph,  or  it  may  have  upon  it  large 
greenish  sloughs.  The  edges  are  thin  and  undermined.  The 
discharge  is  very  profuse  and  ichorous,  excoriating  the 
surrounding  parts.  The  adjacent  cutaneous  surface  is  in- 
flamed and  edematous,  and  there  is  much  burning  pain.  In 
some  cases  the  glands  in  the  groin  enlarge.  Constitution- 
ally, there  is  gastro-intestinal  derangement,  but  rarely  fever. 
When  the  ulcer  spreads  with  great  rapidity  and  becomes 
deeper  as  well  as  larger  in  surface-area,  it  is  called  "  phage- 
denic." The  formation  of  sloughs  indicates  that  tissue-death 
is  going  on  so  rapidly  that  the  dead  portions  have  not  time 
to  break  down  and  be  cast  off.  Limited  stasis  produces 
molecular  death ;  more  extensive  stasis,  a  slough.  If  a 
chronic  ulcer  becomes  acute,  the  granulations  are  destroyed. 

Treatment. — In  treating  an  acute  ulcer  of  the  leg,  give  a 
dose  of  blue  mass  or  calomel,  followed  in  eight  or  ten  hours 
by  a  saline  (3ij  each  of  Rochelle  and  Epsom  salt),  and  order 
light  diet.  Deny  stimulants  except  in  a  case  of  diphtheritic 
ulcer.  Administer  opium  if  pain  is  severe.  Spray  the  ulcer 
with  hydrogen  peroxid,  use  the  scissors  and  forceps  to  get 
rid  of  sloughs,  and  after  sloughs  are  removed  wash  the  ulcer 
with  corrosive  sublimate  solution  (i  :  looo),  or  paint  it  with 
pure  carbolic  acid.  Paint  the  skin  adjacent  to  the  ulcer  with 
equal  parts  of  tincture  of  iodin  and  alcohol.  Dress  with  hot 
antiseptic  fomentations.  Apply  a  bandage  from  the  toes  to 
well  above  the  ulcer.  Insist  on  the  patient  remaining  in  bed 
with  the  leg  slightly  elevated.  Change  the  dressings  before 
they  cool  and  always  as  soon  as  they  are  saturated  with 
discharge.  Every  day  paint  iodin  on  the  parts  about  the 
ulcer. 

Many  cases  do  very  well  after  antiseptization,  and  dusting 
the  ulcer  with  iodoform,  lead-water  and  laudanum  being 
applied  to  the  inflamed  parts  around  the  ulcer ;  but  in  a  bad 
case  hot  antiseptic  fomentations,  compression,  and  elevation 
are  more  useful  until  sloughs  separate.  If  the  discharge  is 
offensive,  apply  acetanilid,  aristol,  or  iodoform,  or  use  gr.  iij 
of  chloral  to  every  5J  of  water,  before  applying  hot  fomenta- 
tions or  ordinary  antiseptic  dressing.     A  25  per  cent,  oint- 


CHRONIC   ULCER    OF   THE   LEG.  1 43 

ment  of  ichthyol  is  very  useful  applied  around  the  ulcer. 
If  sloughs  continue  to  form,  touch  with  a  i  :  8  solution  of 
acid  nitrate  of  mercury  or  with  a  solution  of  pure  carbolic 
acid,  and  reapply  antiseptic  fomentations.  If  an  ulcer  con- 
tinues to  spread,  clean  it  with  peroxid  of  hydrogen,  dry  with 
absorbent  cotton,  touch  with  nitrate-of-mercury  solution 
(i  :  8),  and  apply  an  antiseptic  fomentation.  Repeat  the 
application  of  nitrate  of  mercury  every  day  until  the  ulcer 
ceases  to  extend  and  granulations  begin  to  form.  When 
granulations  begin  to  form  the  moist  hot  dressings  are  no 
longer  necessary,  and  dry  aseptic  or  antiseptic  dressings  can 
be  used. 

In  an  ulcer  covered  with  a  great  mass  of  aplastic  lymph 
touch  daily  with  a  solution  of  silver  nitrate  (gr.  xl  to  5J)  or 
with  acid  nitrate  of  mercury  (i  :  15),  and  dress  with  iodo- 
form and  antiseptic  fomentations.  Give  internally  tonics, 
stimulants,  and  good  food.  In  any  case,  when  granulations 
form,  dress  antiseptically  with  dry  dressings,  or  employ  a 
non-irritant  ointment,  such  as  cosmolin.  If  granulations 
form  slowly,  touch  them  every  day  with  a  solution  of  sil- 
ver nitrate  (gr.  x  to  §j)  and  dress  antiseptically,  or  apply  a 
stimulating  ointment  (resin  cerate  or  Z]  of  ung.  hydrarg. 
nitratis  to  3vij  of  ung.  petrolii,  or  an  ointment  of  copper  sul- 
phate, gr.  iij  to  §j),  or  dress  with  gauze  soaked  in  a  solution 
of  3  drops  of  nitric  acid  to  §j  of  gum  Arabic. 

Chronic  ulcer  of  the  leg  is  characterized  by  low  action 
and  slow  progress.  It  may  be  chronic  from  the  start,  or  it 
may  result  from  acute  ulcer.  More  usually  it  is  found  as  a 
solitary  ulcer  two  inches  above  the  internal  malleolus.  Syph- 
ilitic ulcers  often  occur  in  a  group,  are  usually  crescentic, 
and  are  frequent  upon  the  front  of  the  knee.  A  tubercular 
ulcer  may  have  no  granulations,  but  is  usually  covered  with 
pale  edematous  granulations,  which  signify  the  existence  of 
a  tendency  to  venous  stasis.  The  edges  of  the  tubercular 
ulcer  are  undermined  and  irregular,  the  parts  about  it  are 
livid  and  tender,  and  the  discharge  is  thin  and  scanty  (p.  194). 
An  ordinary  chronic  ulcer  is  circular  or  oval,  and  is  sur- 
rounded by  congested,  discolored,  and  indurated  skin,  this 
induration  being  due  to  fibrous  tissue,  and  there  is  often  ec- 
zema or  a  brown  pigmentation  of  the  neighboring  skin.  The 
floor  of  the  ulcer  is  uneven,  and  usually  is  covered  with 
granulations,  each  of  which  is  red  and  the  size  of  a  pin-point, 
but  which  may  be  exuberant  or  edematous.  If  granula- 
tions are  absent,  the  ulcer  has  the  appearance  of  a  piece  of 
liver,  or  is  smooth  and  glazed.     The  edges  are  thick,  turned 


144  ULCERATION  AND   FISTULA. 

out,  and  not  sensitive  to  the  touch.  Occasionally,  but 
rarely,  they  are  thin  and  undermined.  Some  ulcers  are 
indurated  and  adherent;  this  adhesion  to  the  deeper  struct- 
ures prevents  healing  by  antagonizing  contraction.  An 
ulcer  may  fail  to  heal  because  of  severe  infection ;  because 
of  want  of  rest ;  because  of  absence  of  granulations,  the 
result  of  deficient  blood-supply ;  because  of  edematous 
granulations;  because  of  exuberant  granulations;  because 
of  adhesion  to  deep  structures,  and  because  of  some  con- 
stitutional disease. 

Treatment. — In  treating  a  chronic  ulcer,  give  a  saline 
cathartic  every  day  or  so.  Treat  any  existing  diathesis.  In- 
sist on  rest  and,  if  possible,  elevation.  Asepticize  the  ulcer. 
Draw  blood  by  shallow  scarifications  of  the  bottom  and 
edges  of  the  ulcer   and  the  skin  about  it.     If  the  ulcer  is 

adherent  to  deeper  structures, 
make  incisions  like  those 
shown  in  Fig.  45,  each  cut 
going  through  the  deep  fas- 
cia. These  incisions,  besides 
permitting  contraction,  allow 
granulations     to     sprout     in 

Fig.  4S.-Incisions  for  adherent  uTcer.  the  CUtS  and  absOrb    CXudatC. 

After  incision  keep  the  part 
elevated  and  dressed  antiseptically  for  two  days.  In  two 
days  after  scarification  or  incision  scrape  the  ulcer  with  a 
curet  until  sound  tissue  is  reached.  Use  hot  antiseptic 
fomentations  for  two  days  more,  then  paint  around  the  ulcer 
with  tincture  of  iodin  and  alcohol  (i  :  3),  dress  the  parts 
about  the  ulcer  with  ichthyol  ointment,  and  dress  the  ulcer 
antiseptically  or  with  sterile  gauze.  In  a  day  or  so  the  use 
of  ichthyol  can  be  discontinued  and  the  ulcer  can  be  dressed 
antiseptically  with  sterile  gauze,  normal  salt  solution,  boric 
acid,  bichlorid  of  palladium,  chlorin-water,  a  solution  of  per- 
manganate of  potassium,  sulphur,  glutol,  protonuclein,  or 
bovinin.  Glutol  (formahn-gelatin)  is  very  useful  in  some 
cases  and  so  is  protonuclein.  When  healing  begins,  treat 
as  outlined  for  healing  acute  ulcer  (p.  143). 

Complications. — Remove  by  scissors  and  forceps  any 
badly  damaged  tissue.  Take  out  dead  bone ;  slit  sinuses  ; 
trim  overhanging  edges.  Treat  eczema  by  attention  to  the 
bowels  and  stomach,  and  locally  by  washing  with  ethereal 
soap  and  by  the  use  of  powdered  oxid  of  zinc  or  borated  tal- 
cum, the  leg  being  wrapped  in  cotton.  In  eczema,  avoid  ordi- 
nary soap,  grease,  and  ointment.     Varicose   veins  demand 


COMPLICA  TIONS. 


14: 


either  ligation  at  se\'eral  points,  excision,  circumcision  by 
Schede's  method  (p.  348),  or  the  continued  use  of  a  flannel 
roller-  or  a  Martin  rubber-bandage.  Xe\er  operate  on  vari- 
cose veins  if  phlebitis  exists.  Inflammation  is  met  by  rest, 
elevation,  painting  the  neighboring  parts  with  dilute  iodin, 
and  applying  about  the  ulcer  ichthyol  ointment.  For  cal- 
loused edges,  blister,  employ  radiating  incisions,  or  cut  the 
edges  away.  Ordinar>^  thick  edges  should  be  strapped.  In 
strapping  use  adhesive  plaster  and  do  not  completely  encircle 
the  limb  (Fig.  46).    Edematous  granulations  require  dr\'  dress- 


FiG.  46. — Strapping  of  ulcer  of  leg  (after  Listen). 


ings  and  pressure  by  a  flannel-bandage,  a  rubber-bandage,  or 
adhesive  plaster.  When  the  parts  are  adherent  the  ulcer  is 
immovable,  being  firmly  anchored  to  structures  beneath  it.  In 
such  a  condition  completely  or  partly  surround  the  sore 
with  a  cut  through  the  deep  fascia  (Fig.  45).  This  cut  sets 
the  ulcer  free  from  its  anchorage  and  permits  it  to  contract. 
If  the  bottom  of  the  ulcer  is  foul,  dr\'  it  and  touch  with  a  solu- 
tion of  acid  nitrate  of  mercury  (i  :  8)  or  with  crystals  of  pure 
carbolic  acid.  Repeat  this  every  third  day  and  dress  with 
hot  antiseptic  fomentations  until  granulations  appear.  Super- 
fluous granulations  (proud  flesh)  should  be  cut  away  with 
scissors,  scraped  away,  or  burned  down  with  a  strong  solu- 
tion of  silver  nitrate  or  with  the  solid  stick  of  lunar  caustic. 
Absence  of  granulations  or  scantiness  of  granulations  means 
deficiency  of  blood-supply.  The  surgeon  endeavors  to 
bring  more  blood  to  the  part,  and  to  do  this  induces  inflam- 
mation. The  usual  method  of  procedure  is  to  apply  daily 
10 


146  ULCERATION  AND   FISTULA. 

to  the  sore  a  solution  of  nitrate  of  silver  (10  to  15  grains 
to  the  ounce).  In  obstinate  cases  blister  the  ulcer  or  scrape 
it,  or  paint  it  with  tincture  of  iodin,  or  apply  pure  carbolic 
acid,  or  touch  it  with  the  actual  cautery. 

Irritable  ulcer  is  due  to  exposure  of  a  nerve  and  destruc- 
tion of  its  sheath.  Find  with  a  probe  the  painful  granula- 
tion and  divide  it  with  a  tenotome,  or  curet  the  ulcer  or  burn 
it  with  the  solid  stick  of  silver  nitrate.  If  healing  entirely  fails, 
skin-graft.  Among  the  methods  of  skin-grafting  are — (i) 
Reverdin's,  (2)  Thiersch's,  and  (3)  Krause's.  (See  Plastic 
Surgery.) 

When  a  man  having  an  ulcer  must  go  out  and  about,  use 
a  firmly  applied  roller-,  or,  better  still,  a  Martin  bandage. 
This  bandage,  which  is  made  of  red  rubber,  limits  the  amount 
of  arterial  blood  going  to  the  ulcer  and  favors  venous  flow 
from  the  sore  and  its  neighborhood.  The  bandage  should 
be  used  as  follows  :  before  getting  out  of  bed  spray  the  sore 
with  hydrogen  peroxid  by  means  of  an  atomizer,  dry  off  the 
froth  with  absorbent  cotton,  wash  the  leg  with  soap  and 
water,  dry  it  with  a  towel,  dust  the  extremity  with  borated 
talcum  powder,  and  put  on  the  bandage — all  of  which  should 
be  done  before  putting  a  foot  to  the  floor.  At  night,  after 
getting  on  the  bed,  remove  the  bandage,  wash  it  with  soap 
and  water,  dry  it  with  a  towel,  hang  it  unrolled  over  a  chair, 
and  again  cleanse  the  leg  and  ulcer.  If  these  rules  are  not 
strictly  observed,  the  Martin  bandage  will  produce  pain,  sup- 
puration, and  eczema  of  the  leg. 

Tubercular  Ulcers  (see  p.  194). 

Syphilitic  Ulcers  (see  p.  250). 

A  healthy  ulcer  is  covered  with  small,  bright-red  granu- 
lations which  do  not  bleed  on  touching,  are  painless,  and 
grow  rapidly.  The  edges  are  soft  and  show  the  opalescent 
blue  line  of  proliferating  epithelium.  The  sore  is  movable, 
the  discharge  is  purulent  and  yellow,  and  the  parts  about 
are  not  inflamed. 

Various  XJlcefS. — The  fung-ous  or  exuberant  ulcer  is 
produced  by  interference  with  the  return  of  venous  blood  from 
the  part,  and  it  is  specially  common  after  burns  and  other 
injuries  when  cicatricial  contraction  causes  venous  obstruc- 
tion. The  granulations  are  large,  deep  red  in  color,  bleed 
when  touched,  form  rapidly,  and  mount  above  the  level  of 
the  skin.  The  discharge  from  a  fungous  ulcer  is  profuse, 
thin,  and  bloody.  In  the  treatment  of  such  an  ulcer  venous 
return  must  be  favored  by  bandaging  and  by  elevation  of 
the  part.     If  the  edges  are  very  thick,  divide  them  in  a  num- 


VARIOUS   ULCERS.  1 47 

ber  of  places.  The  superfluous  granulations  should  be  burnt 
off  with  lunar  caustic  or  cut  off.  Strapping  with  adhesive 
plaster  or  the  use  of  a  rubber-bandage  does  good.  The 
sore  can  be  dressed  with  europhen,  aristol,  or  dry  aseptic 
gauze. 

A  varicose  -ulcer  is  an  ulcer  complicated  by  varicose 
veins.  It  is  usually  single,  is  oval,  round,  or  irregular  in 
outline,  and  is  most  often  seen  above  the  inner  malleolus. 
Its  edges  are  thick,  everted,  and  swollen.  The  swelling  is 
largely  due  to  edema,  and  is  found  to  pit  on  pressure.  The 
edges  are  not  undermined,  but  slope  gently  to  the  floor  of 
the  ulcer.  The  floor  is  usually  covered  with  rather  large 
granulations  which  bleed  freely  on  touching.  In  a  varicose 
ulcer  the  destruction  of  tissue  often  begins  at  the  margin  of 
a  congested  area  and  advances  toward  the  center.  Such  an 
ulcer  is  usually  surrounded  by  eczema.  To  aid  the  healing 
of  a  varicose  ulcer  it  is  first  of  all  necessary  to  favor  the 
return  of  venous  blood  from  the  part  by  position  and 
bandaging.  Martin's  bandage  is  very  useful.  It  may  be 
necessary  to  operate  on  the  veins. 

Brethistie,  irritable,  or  painful  ulcers,  which  are  very 
sensitive,  are  due  to  the  exposure  of  nerve-filaments  and 
destruction  of  their  sheaths.  They  are  especially  found  near 
the  ankle,  over  the  tibia,  in  the  anus  (fissure),  or  in  the 
matrix  of  the  nail  (ingrowing  nail).  Curet  an  erethistic  ulcer, 
and  touch  with  pure  carbolic  acid  or  with  the  solid  stick  of 
silver  nitrate.  Chloral,  gr.  xx  to  the  ounce,  allays  the  pain  ; 
so  do  cocain  and  eucain  for  a  time. 

The  indolent  ulcer  shows  no  tendency  to  heal.  In  such 
an  ulcer  there  is  usually  venous  congestion  from  varicose 
veins  or  from  cardiac  weakness.  A  great  mass  of  scar-tissue 
forms  at  the  base  and  edges,  which  fastens  the  ulcer  to  bone 
or  fascia,  so  that  the  edges  cannot  contract.  Healthy  gran- 
ulations cease  to  form.  Varicose  ulcers  are  apt  to  become 
indolent.  The  edges  of  such  an  ulcer  are  thick,  smooth, 
immovable,  and  free  from  tenderness.  Granulations  are 
entirely  absent  or  there  are  seen  here  and  there  a  few 
unhealthy  granulations.  The  discharge  is  thin,  seropuru- 
lent,  and  offensive.  The  parts  about  the  ulcer  are  congested 
and  pigmented.  The  pigmentation  is  due  to  the  fact  that  in 
an  area  of  chronic  congestion  numbers  of  red  blood-cells  have 
been  disintegrated.  Such  an  ulcer  is  treated  by  making 
incisions  to  loosen  the  base  and  edges,  so  that  contraction 
can  take  place,  correcting  the  venous  congestion  by  means 
of  position,  the  use  of  compression  and  cardiac   stimulants, 


148  ULCERATION  AND   FISTULA. 

and  the  employment  of  stimulating  applications  to  the  ulcer 
in  order  to  increase  the  supply  of  arterial  blood. 

The  callous  ulcer  is  the  most  chronic  form  of  indolent 
ulcer  and  is  sunken  deeply  below  the  level  of  the  skin.  Its 
border  is  hard  and  knobby.  Its  floor  shows  no  granula- 
tions, and  is  either  smooth  and  glistening  or  foul  and  liver- 
colored.  The  discharge  is  thin  and  scanty,  and  the  ulcer 
varies  little  in  appearance  from  week  to  week  or  even  from 
month  to  month.  The  treatment  consists  in  scraping  and 
cauterization  of  the  ulcer  ;  cutting  through  the  edges  by 
radiating  incisions  ;  application  of  antiseptic  dressings  and  a 
lirm  bandage.  In  some  cases  strap  the  ulcer.  In  severe 
cases  extirpate  the  ulcer  and  apply  skin-grafts. 

The  hemorrhag-ic  ulcer  bleeds  easily  and  profusely.  Press- 
ure must  be  applied,  and  it  is  sometimes  necessary  to  cut 
away  or  burn  away  the  granulations. 

Phagedenic  Ulcer. — The  phagedenic  ulcer  results  from 
the  profound  microbic  infection  of  tissues  debilitated  by  local 
or  constitutional  disease,  and  is  commonly  venereal.  This 
ulcer  has  no  granulations  and  is  covered  with  sloughs  ;  its 
edges  are  thin  and  undermined,  and  it  spreads  rapidly  in  all 
directions.  It  requires  the  use  of  strong  caustics  or  Paque- 
lin's  cautery,  followed  by  iodoform  dressing  and  antiseptic 
fomentations.     Internally  use  tonics  and  stimulants. 

The  edematous  ulcer  may  result  from  impediment  to 
the  venous  return  or,  as  Nancrede  points  out,  may  be  pro- 
duced by  the  persistent  use  of  poultices  or  wet  dressings 
upon  any  ulcer.^  It  is  most  often  met  with  in  tubercular 
processes  and  is  occasionally  seen  when  varicose  veins  exist. 
The  granulations  are  large  and  pale,  and  are  apt  to  bend 
over  like  unsupported  vines.  The  discharge  is  profuse  and 
seropurulent.  The  edges  are  softened  and  desquamating. 
An  edematous  ulcer  requires  dry  dressings,  stimulation,  and 
compression. 

A  rodent  or  Jacob's  ulcer  is  a  superficial  epithelioma 
developing  from  sebaceous  glands,  sweat-glands,  or  hair- 
follicles.  It  requires  scraping  and  cauterization,  or,  what  is 
better,  excision. 

Marjolin's  ulcer  is  an  epithelioma  arising  from  a  chronic 
ulcer. 

Decubitus,  or  bed-sore,  is  due  to  pressure  upon  an  area  of 
feeble  circulation  (p.  164).    It  is  really  a  condition  of  gangrene. 

Neuroparalytic  or  trophic  ulcer  is  due  to  impairment  of 
the  trophic  centers  in  the  cord. 

1  Principles  of  Surgery. 


FISTULA.  149 

The  perforating  ulcer,  as  it  A\as  named  by  Vesigne,  com- 
monlv  affects  the  metatarsophalangeal  joint  or  the  pulp  of 
the  great  toe  about  a  corn.  The  parts  about  the  corn  in- 
flame, and  pus  forms  and  reaches  into  the  bone.  A  smus 
evacuates  the  pus  by  the  side  of  the  corn.  As  this  ulcer 
may  be  present  in  anesthetic  leprosy,  in  a  paralyzed  limb,  and 
tabes  dorsahs,  and  as  the  part  on  which  it  occurs  is  apt  to 
be  sweatv,  cold,  and  more  or  less  anesthetic,  and  as  the  sore 
may  be  hereditary,  it  is  usually  set  down  as  trophic  in  origin. 
Treatment  of  a '  perforating  ulcer  consists,  according  to 
Treves,  in  going  to  bed  and  poulticing.  Every  time  a  poul- 
tice is  removed  the  raised  epithehum  around  the  ulcer  is  cut 
away  and  then  the  poultice  is  reapplied.  In  about  two 
weeks  an  ulcer  remains  surrounded  by  healthy  tissue.  Treves 
treats  this  sore  with  glycerin  made  to  a  creamy  consistency 
with  salicvlic  acid,  to  each  ounce  of  which  TU^  of  carbolic 
acid  have  been  added.  He  directs  the  patient  to  wear  during 
the  rest  of  his  life  some  form  of  bunion-plaster  to  keep  off 
pressure.  Nerve-stretching  has  been  recommended  as  the 
proper  treatment  for  perforating  ulcer.  If  in  a  perforating 
ulcer  the  bone  is  diseased,  it  must  be  removed.  This  ulcer 
tends  to  recur  in  the  same  spot  or  in  adjacent  parts,  and  it 
mav  be  necessary  to  amputate  the  toe  or  the  foot. 

The  scorbutic  ulcer  is  covered  with  a  dark-brown  crust, 
beneath  which  are  pale  and  bleeding  granulations.  The 
parts  adjacent  are  of  a  violet  color. 

Epitheliomatous,  sarcomatous,  tubercular,  and  syphilitic 
ulcers  are  considered  under  these  respective  diseases. 

Fistula. — A  fistula  is  an  abnormal  communication  be- 
tween the  surface  and  an  internal  part  of  the  body,  or 
between  two  natural  cavities  or  canals.  The  first  form  is 
seen  in  a  rectal  fistula,  *  urethral  fistula,  or  a  biliar}'  fistula ; 
and  the  second  form  is  seen  in  a  vesicovaginal  fistula.  Fis- 
tulse  may  result  from  congenital  defect,  as  when  there  is  fail- 
ure in  the  closure  of  the  branchial  clefts,  and  can  arise  from 
sloughing,  traumatism^,  and  suppuration.  Fistulae  are  named 
from  their  situation  and  communications. 

A  sinus  is  a  tortuous  track  opening  usually  upon  a  free 
surface  and  leading  down  into  the  cavity  of  an  imperfectly 
healed  abscess.  A  sinus  may  be  an  unhealed  portion  of  a 
wound.  Many  sinuses  are  due  to  pus  burrowing  subcu- 
taneously.  A  sinus  fails  to  heal  because  of  the  presence  of 
some  irritant  fluid,  as  saliva,  urine,  or  bile ;  because  of  the 
existence  of  a  foreign  body,  as  dead  bone,  a  bit  of  wood,  a 
bullet,  a  septic   hgature,  etc.;  or  because  of  rigidity  of  the 


I50      MORTIFICATION,    GANGRENE,    OR   SP II A  CELL'S. 

sinus-walls,  which  rigidity  will  not  permit  collapse.  Sinuses 
may  be  maintained  by  want  of  rest  (muscular  movements) 
and  general  ill-health.  The  walls  of  a  tubercular  sinus  are 
lined  with  a  material  identical  with  the  pyogenic  membrane 
of  a  cold  abscess. 

Treatment. — In  treating  a  fistula  or  a  sinus,  remove  any 
foreign  body,  lay  the  channel  open,  curet,  brush  with  pure 
carbolic  acid,  and  pack  with  iodoform  gauze.  In  obstinate 
cases  entirely  extirpate  the  fibrous  walls,  sew  the  deeper 
parts  of  the  wound  with  buried  catgut  sutures,  and  approxi- 
mate the  skin-surfaces  with  interrupted  sutures  of  silkworm- 
gut.  Fresh  air  is  a  necessity,  and  nutritious  food  and  tonics 
must  be  ordered. 

VIII.  MORTIFICATION,  GANGRENE,  OR   SPHACELUS. 

Mortification,  or  gangrene,  is  death  in  mass  of  a  portion  of 
the  living  body — the  dead  portions  being  large  enough  to  be 
visible — in  contrast  to  ulceration,  or  molecular  death,  in 
which  the  dead  particles  have  been  liquefied,  cannot  be 
seen,  and  are  cast  away.  When  all  the  tissues  of  a  part  are 
dead  the  process  is  spoken  of  as  sphacelous.  Gangrene  is 
in  reality  a  form  of  necrosis,  but  clinically  the  term  necrosis 
is  restricted  to  molar  death  of  bone  or  to  death  of  parts 
below  the  surface  en  masse.  In  gangrene  a  portion  of  tissue 
dies  because  of  anemia,  and  the  dead  portions  may  either 
desiccate  or  putrefy.  Gangrene  may  be  due  to  tissue-injury, 
either  chemical  or  mechanical,  to  heat  or  cold,  to  failure  of 
the  general  health,  to  circulatory  obstruction,  to  nerve-dis- 
order, the  nerves  involved  being  the  vasomotor  or  possibly 
the  trophic,  or  to  microbic  infection.  A  microbic  poison  can 
directly  destroy  tissues.  It  can  indirectly  destroy  them  by 
causing  such  inflammation  that  the  products  obstruct  the 
circulation,  but  gangrene  can  occur  when  no  bacteria  are 
present.  The  essential  cause  of  gangrene  is  that  the  tissues 
are  cut  off  from  a  due  supply  of  nourishment,  and  cell-nutri- 
tion is  no  longer  possible.  In  other  words,  the  essential 
cause  of  gangrene  is  the  cutting  off  of  arterial  blood.  Nan- 
crede  says  :  "  Indeed,  except  when  the  traumatism  physically 
disintegrates  tissues,  as  a  stone  is  reduced  to  powder,  heat 
or  strong  acids  physically  destroy  structure,  or  cold  sus- 
pends cellular  nutrition  so  long  that  when  this  nutrition 
becomes  a  physical  possibility  vital  metabolism  cannot  be 
resumed,  gangrene  always  results  from  total  deprivation  of 
pabulum."  ^ 

^  Principles  of  Surgery. 


CLASSIFICATIOX  OF  GAXGREA'E.  I5I 

Classification. — Gangrene  is  divided  into  the  following 
three  great  groups  : 

(i)  Dry  gangrene,  which  is  due  to  circulatory  interference, 
the  arterial  supply  being  decreased  or  cut  off.  The  tissues 
dry  and  mummify. 

(2)  Moist  gangrene,  which  is  due  to  interference  not  only 
with  arterial  ingress,  but  also  with  venous  return  or  capillary 
circulation,  the  dead  parts  remaining  moist. 

(3)  Microbic  gangrene,  arising  from  virulent  bacteria.  In 
this  form  the  bacterial  process  causes  the  gangrene,  and  is 
not  merely  associated  with  it. 

The  above  classification,  if  unqualified,  suggests  erroneous 
ideas.  It  indicates  that  there  is  an  essential  difference 
between  dry  gangrene  and  moist  gangrene,  which  is  not  the 
case.  If  when  gangrene  begins  the  tissues  are  free  from 
fluid,  the  patient  de\elops  dry  gangrene ;  if  they  are  full  of 
fluid,  he  develops  moist  gangrene.  If  the  arterial  supply  is 
gradually  cut  off,  the  tissues  are  sure  to  be  free  from  fluid, 
and  the  gangrene  will  certainly  be  of  the  dr}^  form.  If  arte- 
rial blood  is  suddenly  cut  ofl",  the  gangrene  may  be  dr>' 
or  moist,  according  as  to  whether  the  tissues  are  or  are  not 
drained  of  fluid.  When  gangrene  results  from  inflammation, 
strangulation,  and  infection,  it  is  certain  to  be  of  the  moist 
variety,  because  the  tissues  are  sure  to  be  filled  with  fluid. 

Nancrede  says,  in  his  ver}^  valuable  work  on  the  Pnii- 
ciples  of  Surgery  :  "  Yet,  let  accidental  inflammation  have 
preceded  the  final  blocking  of  an  artery,  or  let  ligation  of 
the  main  artery  cause  gangrene  because  the  collateral  circu- 
lation cannot  become  developed,  and  if  an  aneurysmal  sac  is 
so  situated  as  to  interfere  with  a  free  return  of  venous  blood 
and  lymph,  this  anemic  gangrene  will  in  both  instances 
prove  moist  and  not  dry." 

There  are  many  gangrenous  processes  which  belong  under 
one  or  other  of 'the  above  heads,  namely:  congenital  gan- 
grene, a  rare  form  existing  at  birth;  constitutional  gangrene, 
arising  from  a  constitutional  cause,  as  diabetes ;  cutaneous 
gangrene,  which  is  limited  to  skin  and  subcutaneous  tissue, 
as  in  phlegmonous  erysipelas;  gaseous  or  emphysematous 
gangrene,  in  w^hich  the  subcutaneous  tissues  are  filled  with 
putrefactive  gases  and  crackle  on  pressure;  hospital  gan- 
grene, which  is  defined  by  Foster  as  specific  serpiginous  ne- 
crosis, the  tissues  being  pulpefied :  some  consider  it  a  trau- 
matic diphtheria ;  cold  gangrene,  a  form  in  which  the  parts 
are  entirely  dead  (sphacelus) ;  hot  gangrene,  which  is  asso- 
ciated with  inflammation,  as  shown  b}'  heat ;  dermatitis  gan- 


152      MORTIFICATION,    GANGRENE,    OR   SPHACELUS. 

grcenosa  infanUnn,  or  the  multiple  cachectic  gangrene  of 
Simon;  idiopatliic  gangrene,  which  has  no  ascertainable 
cause  ;  mixed,  which  is  partly  dry  and  partly  vs\6\sX.\  primary, 
in  which  the  death  of  the  part  is  direct,  as  from  a  burn  ; 
secondary,  which  follows  an  acute  inflammation  ;  vmltiple,  as 
gangrenous  herpes  zoster;  diabetic  or  glyceviic  gangrene, 
which  arises  during  the  existence  of  diabetes ;  gangrenous 
ecthyma,  a  gangrenous  condition  of  ecthyma  ulcers ;  pressure, 
which  is  due  to  long  compression;  purpuric  or  scorbutic, 
which  is  due  to  scurvy ;  Raynaud's  or  idiopathic  symmetrical, 
which  is  due  to  vascular  spasm  from  nerve-disorder ;  senile, 
the  dry  gangrene  of  the  aged ;  venous  or  static,  which  is  due 
to  obstruction  of  circulation,  as  in  a  strangulated  hernia; 
trophic,  which  is  due  to  nutritive  failure  by  reason  of  disorder 
of  the  trophic  nerves  or  centers ;  thrombotic,  which  is  due  to 
thrombus ;  embolic,  which  is  due  to  embolus  ;  and  decubitus, 
decubital  gangrene,  or  bed-sores  due  to  pressure. 

Dry  gangrene  arises  from  deficiency  of  arterial  blood. 
For  this  reason  Nancrede  calls  it  anemic  gangrene. 

This  form  of  gangrene  is  far  more  apt  to  result  from  the 
gradual  than  from  the  sudden  cutting  off  of  the  supply  of 
arterial  blood,  and  is  more  common  if  the  blood-vessels  are 
atheromatous  than  if  they  are  healthy ;  but  even  in  a  person 
with  healthy  arteries  gangrene  will  ensue  upon  blocking  of 
the  main  artery,  if  the  collaterals  fail  to  supply  the  part  with 
blood.  This  form  of  gangrene  can  occur  after  laceration, 
ligation,  or  the  lodgement  of  a  thrombus  in  the  main 
artery  of  a  limb  ;  but  in  such  cases  considerable  fluid  usually 
remains  in  the  tissues  and  the  gangrene  is  apt  to  be  moist 
rather  than  dry. 

Obstruction  due  to  thrombus  is  not  unusual  in  the  diseased 
arteries  of  the  aged,  and  such  obstruction  generally  results  in 
dry  gangrene.  An  embolus  may  cause  dry  gangrene  in  rare 
instances.  If  it  does  so,  it  is  probable  that  the  blocking  was 
not  at  once  complete.  When  an  embolus  lodges  in  an  artery 
and  causes  dry  gangrene,  the  case  runs  the  following  course  : 
sudden  severe  pain  at  the  seat  of  impaction,  and  also  tender- 
ness ;  pulsation  above,  but  not  below,  this  point,  after  ob- 
struction has  become  complete ;  the  limb  below  the  obstruc- 
tion is  blanched,  cold,  and  anesthetic;  within  forty-eight 
hours,  as  a  rule,  the  area  of  gangrene  is  widespread  and 
clearly  evident;  the  hmb  becomes  reddish,  greenish,  blue, 
and  then  black  ;  the  skin  becomes  shrivelled  and  its  outer 
layer  stony  or  like  horn  because  of  evaporation.  The  entire 
part  may  become  dry  ;    but  usually  there  are  spots  where 


DRY  GANGRENE.  I  53 

some  fluid  remains,  and  these  spots  are  soft  and  moist,  and 
the  dead  tissue,  where  it  joins  the  hving,  is  sure  to  be  moist. 
The  moist  areas  become  foul  and  putrid,  but  the  dry  spots 
do  not.  In  dry  gangrene,  at  the  point  of  contact  of  the 
dead  and  Hving  tissues,  inflammation  arises  in  the  latter 
structures,  a  bright-red  line  forms,  and  exudation  and 
ulceration  take  place.  This  line  of  ulceration  in  the  sound 
tissues  is  called  the  "  line  of  demarcation."  It  is  Nature's 
effort  at  amputation,  and  in  time  may  get  rid  of  a  large  por- 
tion of  a  limb,  and  then  heal  as  any  other  ulcer.  A  line  of 
demarcation  rarely  causes  hemorrhage,  because  it  ulcerates 
through  a  vessel  only  after  inflammation  has  caused  occlu- 
sion by  thrombosis.  In  dry  gangrene  from  arterial  obstruc- 
tion there  are  gastro-intestinal  derangement  and  some  fever. 
The  gangrene  does  not  extend  up  to  the  point  of  obstruc- 
tion, but  only  to  a  region  in  which  the  anastomotic  circula- 
tion is  sufficiently  active  to  permit  of  the  formation  of  a  line 
of  demarcation.  Below  this  point  inflammatory  stasis  arises, 
but  before  this  can  go  on  to  ulceration  the  parts  die.  In 
cases  where  the  arterial  obstruction  is  sudden  and  complete 
the  limb  swells  decidedly.  This  is  due  to  the  sudden  loss 
of  vis  a  tergo  in  the  arterial  system,  venous  reflux  occurring 
and  fluids  transuding.  In  such  a  case  the  tissues  contain 
fluid  and  putrefy,  and  the  process,  though  due  to  the  cutting 
off  of  the  arterial  circulation,  is  moist  gangrene.  Dry  gan- 
grene attacks  the  leg  more  often  than  the  arm.  Thrombus 
in  an  artery  rarely  causes  gangrene  except  in  the  aged,  as 
the  collateral  circulation  has  time  to  adjust  itself;  but  gan- 
grene may  follow  thrombus,  and  when  it  does  it  comes  on 
more  slowly  than  does  gangrene  from  embolus,  and  is  certain 
to  be  of  the  dry  form. 

Treatment  of  Non-senile  Dry  Gangrene. — When  injur}'  of 
a  healthy  artery  causes  us  to  fear  dry  gangrene  the  patient 
should  be  placed  in  bed  and  the  part  elevated  a  little,  kept 
wrapped  in  cotton-wool  and  warmed  with  hot  bottles  or 
hot  water-bags.  The  dying  part  is  dressed  antiseptically, 
and  the  surgeon  sees  to  it  that  the  patient  gets  plenty  of 
sleep  and  nourishment.  It  is  advisable  to  give  tonics  and 
stimulants.  Wait  for  a  line  of  demarcation  and  amputate 
well  above  it. 

Senile  gangrene,  chronic  gangrene,  Pott's  gangrene 
(Fig.  47),  is  a  form  of  gangrene  due  to  feeble  action  of  the 
heart  plus  obliterating  endarteritis  or  atheroma  of  peripheral 
vessels.  The  vessels  do  not  properh'  carrv'  blood,  and  may 
at  any  time  be  occluded  by  thrombosis.     In  a  drunkard,  or 


154      MORTIFICATION,    GANGRENE,    OR   SPHACELUS. 

in  a  victim  of  syphilis  or  tubercle,  the  changes  supposed  to 
characterize  old  age  may  appear  while  a  man  is  young  in' 
years.     It  was  long  ago  said,  with  truth,  "  a  man  is  as  old  as 


-Senile  gangrene  of  the  feet  (Gross). 


his   arteries."     Senile  gangrene  most  often  occurs  in  a  toe 
or  the  foot. 

Symptoms. — A  man  whose  vessels  are  in  the  state  above 
indicated  is  generally  in  feeble  health  and  has  a  fatty  heart 
and  an  arcus  senilis  (a  red  or  white  line  of  fatty  degeneration 
around  the  cornea).  His  toes  and  feet  feel  cold  and  numb, 
and  they  "  go  to  sleep  "  very  easily,  and  he  suffers  from 
cramp  of  the  legs  and  feet.  He  is  dyspeptic  and  short  of 
breath,  and  his  urine  is  frequently  albuminous.  The  arte- 
ries are  felt  as  rigid  tubes,  like  pipe-stems.  He  is  in  danger 
of  edema  of  the  lungs  and  of  dry  gangrene  of  the  toes.  A 
slight  injury  of  a  toe,  for  instance,  cutting  a  corn  too  close, 
will  produce  extensive  inflammatory  stasis  followed  by 
thrombosis,  which  completely  cuts  off  the  blood-supply  and 
causes  gangrene  of  the  part.  Gangrene  is  usually  announced 
by  the  appearance  of  a  purple  and  anesthetic  spot,  followed 
by  a  vesicle  which  ruptures  and  liberates  a  small  amount  of 
bloody  serum  and  exposes  a  dry  floor.  In  the  parts  about 
the  gangrenous  area  there  is  often  burning  pain.  The  tissues 
immediately  adjacent  to  the  dead  spot  are  in  a  condition  of 
edema  and  stasis,  the  parts  being  purple,  the  color  disap- 
pearing slowly  under  pressure  and  returning  slowly  when 
pressure  is  removed.  The  parts  a  little  further  removed  are 
edematous  and  hyperemic,  the  color  disappearing  rapidly 
on  pressure  and  returning  rapidly  when  pressure  is  removed. 
The  dead  parts  do  not  putrefy  at  all  or  do  so  but  slightly, 
hence  the  odor  is  never  very  offensive  and  is  usually  trivial. 
They    are    anesthetic,   hard,   leathery,    and    wrinkled,    and 


SENILE    GANGRENE.  I  55 

resemble  a  varnished  anatomical  specimen  or  the  extremity 
of  a  mummy  (hence  the  term  mummification).  Before  the 
line  of  demarcation  forms  there  is  burnin<^  pain ;  after 
it  forms  pain  is  rarely  present.  If  embolism  or  thrombus  in 
a  diseased  vessel  caused  the  gangrene,  the  pain  is  severe.  In 
senile  gangrene  the  periphery  is  always  dry,  the  part  nearer 
the  body  being  generally  somewhat  moist.  The  process 
may  be  very  limited  or  it  may  spread  up  to  the  knee.  As  it 
spreads  the  area  of  hyperemia  advances  at  the  margin,  the 
area  of  stasis  follows,  and  the  zone  of  gangrene  becomes 
more  extensive.  When  tissues  are  reached  the  blood-supply 
of  which  is  sufficiently  good  to  permit  of  inflammation, 
Nature  tries  to  limit  the  gangrene  by  the  formation  of  a  line 
of  demarcation.  A  line  of  demarcation  may  begin,  but  prove 
abortive,  the  tissue  mortifying  above  it.  This  proves  that 
tissue  near  the  line  is  in  a  state  of  low  vitality.  When  a 
limited  area  is  gangrenous  constitutional  symptoms  are 
trivial  or  absent,  but  when  a  large  area  is  involved  the 
fever  of  septic  absorption  exists.  Death  may  ensue  from  ex- 
haustion caused  by  sleeplessness  and  pain,  from  septic 
absorption,  or  from  embolism  of  internal  organs.  In  many 
cases  of  senile  gangrene  thrombosis  arises  in  the  superficial 
femoral  artery  or  its  branches  (Heidenhain),  an  observation 
it  is  important  to  bear  in  mind  when  amputating. 

Prevention  of  Senile  Gangrene  in  the  Predisposed. — We 
should  caution  such  a  patient  to  avoid  injuring  his  toes  and 
feet.  Cutting  his  corns  carelessly  is  highly  dangerous, 
and  any  wound,  however  slight,  requires  rest  and  anti- 
septic dressing.  The  victim  of  general  atheroma  must  wear 
woollen  stockings,  put  a  hot-water  bag  to  his  feet  on 
cold  nights,  and  attend  to  his  general  health.  A  little 
whiskey  after  each  meal  is  indicated,  and  occasional  courses 
of  nitroglycerin  are  desirable. 

Treatment  of  Senile  Gangrene. — When  gangrene  occurs, 
if  it  is  limited  to  one  toe  or  a  portion  of  several  toes,  if  it  is  a 
first  attack,  if  there  is  no  fever  or  exhausting  diarrhea,  if  there 
is  no  tendency  to  pulmonary  congestion,  if  the  appetite  is 
fair  and  sleep  refreshing,  it  is  best  to  avoid  radical  inter- 
ference. Await  the  formation  of  a  line  of  demarcation. 
While  awaiting  the  line  of  demarcation  dress  the  part  anti- 
septically  and  raise  the  foot  several  inches  from  the  bed  ; 
apply  warmth,  give  the  patient  nourishing  diet,  stimulants, 
and  tonics  ;  see  to  it  that  he  sleeps,  and  during  the  spread  of 
the  gangrene  watch  for  fever,  diarrhea,  pulmonary  congestion, 
and  kidney-failure.    When  a  line  of  demarcation  forms,  dress 


156      MORTIFICATION,    GANGRENE,    OR   SPHACELUS. 

with  antiseptic  fomentations  and  iodoform,  and  every  day 
pick  away  dead  bits  with  the  scissors  and  forceps.  In  many 
cases  heaUng  will  occur ;  but  even  when  the  parts  heal  the 
patient  will  always  be  in  deadly  peril  of  another  attack.  If 
the  gangrene  shows  a  tendency  to  spread,  if  it  involves  more 
than  a  portion  of  several  toes,  if  it  is  not  a  first  attack,  if  there 
is  sleeplessness,  fever,  exhausting  diarrhea,  absent  appetite, 
or  a  strong  tendency  to  pulmonary  congestion,  do  not  delay, 
but  at  once  amputate  high  up.  If  the  gangrene  shows  no 
tendency  to  limit  itself,  or  if  the  patient  develops  sepsis  or 
exhaustion,  at  once  amputate  high  up.  The  best  point  at 
which  to  amputate  is  above  the  knee,  so  that  the  deep 
femoral  artery,  which  rarely  becomes  atheromatous,  will 
nourish  the  flap.  Never  amputate  below  the  tubercle  of  the 
tibia.  Some  operators  disarticulate  at  the  knee-joint.  Heiden- 
hain  affirms  that  so  long  as  the  gangrene  is  limited  to  one  or 
two  toes  we  should  merely  treat  it  antiseptically,  elevate  the 
limb,  and  wait  for  the  dead  part  to  be  cast  off  spontaneously ; 
if,  however,  it  extends  to  the  dorsum  or  sole  of  the  foot,  we 
should  amputate  at  once  above  the  knee.  He  further  states 
that  gangrene  of  the  flaps  almost  always  occurs  in  amputa- 
tion below  the  knee,  and  high  amputation  is  indicated  in 
advancing  gangrene  with  or  without  fever.^  When  amputa- 
tion has  been  performed  and  the  Esmarch  band  has  been 
removed  and  no  arterial  bleeding  takes  place  from  the 
superficial  femoral  artery,  a  clot  is  lodged  in  that  vessel. 
If  such  a  condition  exist,  insert  into  the  artery  a  fine  rubber 
catheter  or  a  filiform  bougie  and  break  up  the  clot.  When 
blood  flows  we  are  sure  that  the  clot  has  been  washed  out.^ 
In  moist  or  acute  g-angrene  (Fig.  48)  the  dead  part  re- 
mains moist  and  putrefies  As  Nancrede  points  out,  there 
are  two  forms  of  moist  gangrene  :  "  that  limited  to  the  areas 
actually  killed  by  a  traumatism,  with  some  surrounding  tissue 
which  dies,"  and  "  that  which  tends  to  spread  widely,  this 
latter  usually  being  caused  by  specific  micro-organisms,  an 
intense,  widespread,  pyogenic  inflammation  resulting,  in- 
volving the  subcutaneous  and  intermuscular  cellular  planes, 
by  strangulation  of  the  vessels  of  which  all  blood-supply  to 
the  remaining  soft  parts  is  destro}'ed."  ^  In  a  case  of 
gangrene  the  parts  remain  moist,  either  because  the  main 
artery  has  become  suddenly  blocked,  and  the  tissue-fluids 
are  unable  to  flow  out  of  the  limb,  or  because  the  main  vein 

1  Deutsche  viedicinische  Wochenschrift,  1891,  p.   1087. 

^  Severeanu.      See    Mancozet's    report    before    the    second    Pan-American 
Medical    Congress.  '^  Nancrede's  Principles  of  Surgery. 


MOIST   GAXGREXE   FROM  IXFLAMMATIOX.  I  57 

is  blocked.  It  may  arise  in  a  limb  after  ligation,  obstruction, 
or  destruction  of  its  main  artery,  main  \ein,  or  both  ;  after 
long  constriction,  as  by  a  tight  bandage ;  after  crushes  and 
lacerated  wounds  ;  and  after  thrombosis  of  the  vein.  Moist 
gangrene  may  follow  acute  inflammation,  or  may  be  due  to 


Fig.  48. — Acute  gangrene  (Gross). 

local  constriction  (strangulated  hernia),  crushing,  chemical 
irritants,  heat,  and  cold. 

Moist  g-angrene  of  a  limb  is  seen  t\-pically  when  both 
vein  and  artery  are  constricted,  damaged,  or  destro}-ed.  The 
leg  swells  greath'  and  is  pulseless  below  the  obstruction  ;  the 
skin,  at  first  pale,  cold,  and  anesthetic,  becomes  li\id,  mot- 
tled, or  purple  or  greenish,  and  is  raised  into  blebs  which 
contain  a  reddish  or  brown  fluid.  "  These  blebs,  being 
caused  by  the  accumulation  of  serum  beneath  epithelium 
which  has  lost  its  vital  connection  with  the  derm,  can  be 
slipped  around  upon  the  surrounding  true  skin,  the  epithe- 
lium readily  separating  for  long  distances  around,  as  in  a 
cadaver"  (Nancrede).  The  extremity  swells  enormously, 
there  is  pain  at  the  seat  of  obstruction,  and  sapremic  symp- 
toms quickly  develop.  The  bullje  break  and  disclose  the 
brown  derm  and  sometimes  the  deeper  structures,  which  are 
swollen  and  edematous.  The  fetor  is  horrible.  The  sapro- 
phytic organisms  may  lead  to  the  formation  of  gas,  and  if 
the  gas  is  retained  in  the  tissues  pressure  with  the  finger  will 
develop  a  sensation  of  crackling.  This  condition  is  known 
as  emphysema.     A  line  of  demarcation  soon  forms. 

Moist  g-angrene  from  inflammation  is  due  to  pressure  of 
the  exudate  cutting  off  the  blood-supply,  or  to  loss  of  blood- 
circulation  because  of  microbic  involvement  of  vessels  and 
clotting  of  blood.  It  occurs  in  phlegmonous  erysipelas. 
When  an  inflammation  is  about  to  terminate  in  gangrene  all 
the  signs  of  inflammation,  local  and  constitutional,  increase ; 
when  gangrene  occurs  they  cease,  bullae  and  emphysema  are 
noted,  with  great  swelling  and  all  the  other  symptoms  of 
molar  death.   The  sudden  cessation  of  pain  is  very  suggestive 


158      MORTIFICATION,    GANGRENE,    OR   SPHACELUS. 

of  gangrene.  The  constitutional  symptoms  are  those  of  sup- 
purative fever  and  sapremia,  or  possibly  of  septic  infection. 

When  a  wound  becomes  gangrenous  the  surface  looks 
like  yellow  or  gray  tow,  the  discharge  becomes  profuse  and 
very  fetid,  and  the  parts  about  swell  enormously  and  gradu- 
ally become  gangrenous. 

Treatment  of  Moist  Gangrene. — In  extensive  moist  gan- 
grene of  a  limb  wait  for  a  line  of  demarcation,  and  amputate 
clear  of  and  above  it.  While  waiting  for  the  line  to  form 
dress  the  dead  parts  antiseptically,  wrap  the  extremity  in 
cotton,  apply  heat,  and  slightly  elevate  the  limb.  Give  opium, 
tonics,  nourishing  food,  and  stimulants.  In  inflammatory 
gangrene  relieve  tension  by  incisions  and  then  cut  away  the 
dead  parts,  brush  the  raw  surface  with  pure  carbolic  acid, 
dust  with  iodoform,  and  dress  with  hot  antiseptic  fomenta- 
tions. Stimulate  freely  and  feed  well.  A  gangrenous  wound 
is  treated  as  pointed  out  in  the  section  on  Sloughing. 

Acute  miorobic  gangrene,  fulminating  gangrene,  gan- 
grenous emphysema,  gangrene  foudroyante,  or  traumatic 
spreading  gangrene,  results  from  a  virulent  infection  of  a 
wound.  The  condition  may  be  due  to  a  mixed  infection 
with  virulent  streptococci  and  organisms  of  putrefaction  ;  or 
to  infection  with  the  bacilli  of  mahgnant  edema,  and  putre- 
factive organisms.  Some  cases  are  due  to  the  bacillus  of 
malignant  edema  alone ;  some  are  due  to  the  bacillus  aero- 
genes  capsulatus  of  Welch  and  Flexner.  The  injury  is  usually 
severe — often  a.  crush  which  destroys  the  main  artery  and 
renders  an  anastomotic  circulation  impossible.  In  such  severe 
accidents  the  limb  is  much  swollen  and  the  pulse  below  the 
seat  of  injury  is  imperceptible,  and  the  surgeon  is  often  at 
this  time  uncertain  whether  to  amputate  at  once  or  wait.  In 
some  cases  traumatic  spreading  gangrene  arises  after  trivial 
injuries.  This  form  of  gangrene  is  commonest  after  com- 
pound fractures,  and  begins  within  forty-eight  hours  of  the 
accident.  The  extremity  becomes  enormously  swollen  from 
edema.  The  gangrene  does  not  begin  at  the  periphery,  as 
does  ordinary  moist  gangrene,  but  at  the  wound-edges, 
which  turn  red,  green,  and  finally  black  ;  the  extremity  soon 
undergoes  a  like  change  and  becomes  mortified.  The  skin 
peels  off,  emphysematous  crackling,  due  to  gas  formed  and 
retained  in  the  tissues,  can  be  detected  over  large  areas,  and 
the  extremity  becomes  anesthetic  and  pulpy.  The  gangrene 
spreads  up  and  down  from  the  wound,  and  red  lines,  due 
to  lymphangitis,  run  from  above  the  wound.  The  adjacent 
lymph-glands  swell,  and  in  thirty-six   hours  the  gangrene 


SPECIAL   FORMS   OF  GAXGREXE.  159 

nia\'  involve  an  entire  limb.  Xo  line  of  demarcation  forms. 
The  system  is  soon  overwhelmed  with  ptomains,  and  the 
patient  suffers  from  septic  intoxication,  and  often  passes  into 
profound  collapse  with  subnormal  temperature.  Traumatic 
spreading  gangrene  must  not  be  confused  with  erysipelas. 
In  erysipelas  the  color  is  red,  pressure  instantly  drives  it  out, 
and  on  the  release  of  pressure  it  at  once  returns.  In  early 
gangrene  the  color  is  purple,  pressure  fails  to  drive  it  out  at 
all  or  only  does  so  very  slowly,  and  if  the  surface  is  blanched 
b}-  pressure,  on  the  release  of  pressure  the  color  crawls 
slowly  back. 

Trcatuitiit. — In  treating  traumatic  spreading  gangrene  a 
line  of  demarcation  need  not  be  waited  for,  as  none  can  form. 
Amputation  should  at  once  be  performed  high  up,  the  flaps 
are  brushed  with  pure  carbolic  acid,  and  stimulants  must  be 
given  in  large  amount. 

Hospital  gangrene  or  sloughing  phagedena  is  a  disease 
that  has  practical!}-  disappeared  from  cixilized  communities. 
It  formerly  occurred  in  crowded,  ill-ventilated  hospitals. 
Some  consider  it  traumatic  diphtheria.  Koch  thinks  it  is 
due  to  streptococci.  Jonathan  Hutchinson  says,  "  hospital 
gangrene  is  set  up  b}*  admitting  to  the  wards  a  case  of 
syphilitic  phagedena."  It  may  show  itself  as  a  diphtheritic 
condition  of  a  wound,  as  a  process  in  which  sloughs  which 
look  like  masses  of  tow  form,  or  as  a  phagedenic  ulcera- 
tion. The  surrounding  parts  are  inflamed  and  painful,  and 
buboes  form  in  adjacent  lymphatic  glands.  The  s}-stem 
passes  into  a  low  septic  state. 

Treatment. — In  treating  hospital  gangrene  ether  should  be 
given,  the  large  sloughs  removed  with  scissors  and  forceps. 
the  parts  dried  with  cotton  and  cauterized  with  bromin.  The 
surgeon  should  take  a  tumblerful  of  water  and  into  it  pour 
the  bromin,  which  will  fall  to  the  bottom  of  the  glass.  The 
drug  can  be  drawn  up  with  a  s\Tinge  and  injected  into  the 
depths  of  the  wound.  The  wound  should  be  plentifully- 
sprinkled  with  iodoform  and  dressed  with  hot  antiseptic 
fomentations.  When  the  sloughs  separate  the  sore  can  be 
treated  as  an  ordinary  ulcer.  The  constitutional  treatment 
is  that  employed  for  sepsis.  If  a  limb  is  hopelessh-  damaged 
by  this  form  of  gangrene,  wait  for  a  line  of  demarcation  and 
amputate. 

Special  Forms  of  Gangrene. — Symmetrical  or  Ray- 
naud's gangrene  arises  in  severe  cases  of  Raynaud's  disease. 
It  is  a  dry  gangrene.  Raynaud's  disease,  a  vasomotor  neu- 
rosis seen  in  children  and  voune  adults,  is  characterized  bv 


l6o      MORTIFICATION,    GANGRENE,    OR   SPHACELUS. 

attacks  of  cold,  dead  bloodlessness  in  the  fingers  or  toes  as  a 
result  of  exposure  to  cold  or  of  emotional  excitement  (local 
syncope).  In  the  more  severe  cases  there  are  capillary  con- 
gestion and  livid  swelling  (local  asphyxia).  A  chilblain  is 
an  area  of  local  asphyxia.  In  Raynaud's  disease  the  patient 
complains  of  pain,  tingling,  and  stiffness  in  the  affected  parts. 
Attacks  of  Raynaud's  disease  occur  again  and  again,  are 
often  accompanied  by  hemoglobinuria,  and  may  never 
eventuate  in  gangrene.  The  pathology  is  uncertain.  Local 
syncope  is  thought  to  be  due  to  vascular  spasm,  and  local 
asphyxia  to  some  contraction  of  the  arterioles,  -with  dilatation 
of  the  capillaries  and  venules.  It  is  after  local  asphyxia  that 
gangrene  may  appear. 

Raynaud's  gangrene  is  most  commonly  met  with  upon 
the  ends  of  the  fingers  or  the  toes,  but  it  may  attack  the 
lobes  of  the  ears,  the  tip  of  the  nose,  or  the  skin  of  the  arms 
or  the  legs.  Sometimes  the  disease  is  seen  upon  the  trunk. 
When  gangrene  is  about  to  occur  the  local  asphyxia  at 
that  point  deepens,  anesthesia  becomes  complete,  and  the 
part  blackens  and  feels  cold  to  the  touch.  The  epidermis 
raises  into  blebs,  which  rupture  and  expose  dry  surfaces. 
A  line  of  demaixation  forms,  and  the  necrosed  area  is 
removed  as  a  slough.  Widespread  gangrene  from  Raynaud's 
disease  is  rare ;  there  is  not  often  a  large  area  involved — 
rather  a  small  superficial  portion. 

Treatment  of  Raynaud's  Disease. — When  attacks  of  Ray- 
naud's disease  are  so  severe  as  to  threaten  gangrene,  put  the 
patient  to  bed ;  if  the  feet  are  affected,  elevate  the  legs 
slightly,  wrap  the  extremities  in  cotton-wool,  and  apply  heat. 
If  the  hands  are  affected,  wrap  them  in  cotton-wool,  elevate 
them  slightly,  and  apply  heat.  Massage  is  useful.  When 
gangrene  occurs,  dress  the  part  antiseptically  until  a  line  of 
demarcation  forms,  and  then  remove  the  dead  parts  by 
scissors,  forceps,  and  antiseptic  fomentations.  If  amputation 
becomes  necessary,  which  will  rarely  be  the  case,  wait  for 
a  line  of  demarcation. 

Diabetic  gangrene  resembles  in  many  points  senile  gan- 
grene, but  the  dead  portions  remain  somewhat  moist  and 
putrefy.  Some  attribute  it  directly  to  sugar  in  the  blood. 
Some  think  the  tissues  are  simply  less  resistant  to  infection. 
Many  hold  that  it  is  of  neurotic  origin.  Heidelhain  be- 
lieves that  it  is  due  to  arterial  sclerosis.  Diabetic  gangrene 
is  most  usually  met  with  upon  the  feet  and  legs  of  elderly 
people,  but  it  may  arise  at  any  age  and  may  attack  the  gen- 
ital organs,  thigh,  lung,  buttock,  eye,  back,  finger,  or  neck. 


GANGRENE   FROM  ERGOTISM.  l6l 

It  may  affect  only  a  single  area,  may  attack  several  areas, 
or  may  be  symmetrical.  It  may  arise  in  any  stage  of 
diabetes  from  the  earliest  to  the  latest.  It  may  begin  as  a 
perforating  ulcer.  As  in  senile  gangrene,  a  trivial  injury  is 
apt  to  be  the  exciting  cause,  but  it  may  arise  without  any 
antecedent  injury.  When  the  gangrene  follows  a  traumatism 
there  are  no  prodromic  symptoms.  When  it  arises  spon- 
taneously in  the  skin  it  is  often  preceded  by  pain  of  a 
neuralgic  nature  and  attacks  of  "  livid  or  violaceous  dis- 
coloration of  the  skin,  with  lowered  surface-temperature  and 
sometimes  loss  of  sensation"  (ElHot).  Diabetic  gangrene  is 
often  superficial,  but  may  become  deep  if  it  follows  an  injury 
or  ulcer.  The  gangrenous  area  is  somewhat  moist  as  a  rule, 
but  may  be  dry.  The  parts  about  are  livid  and  may  be 
covered  with  vesicles.  It  spreads  slowly,  but  more  rapidly 
than  senile  gangrene.  There  is  little  tendency  to  the  forma- 
tion of  any  line  of  demarcation,  although  occasionally  spon- 
taneous healing  occurs.  Surgeons  have  become  shy  of 
amputating  in  such  cases,  but  the  experience  of  Kuster,  of 
Berlin,  proves  conclusively  that  an  amputation  should  be 
performed  at  once  in  diabetic  gangrene  of  the  leg,  and 
should  be  done  above  the  knee.  If  operation  is  performed 
below  the  knee,  the  flaps  will  become  gangrenous.  It  has 
been  noted  that  sugar  will  sometimes  disappear  from  the 
urine  after  an  amputation.  Of  1 1  amputations  by  Kuster, 
6  recovered  and  5  died;  and  of  these  5,  3  had  albumin  in 
the  urine  as  well  as  sugar.^ 

Heidelhain  warmly  advocates  early  high  amputation,  with 
the  making  of  short  flaps.  When  the  patient  dies' after 
operation,  he  usually  does  so  in  coma.  In  any  case  after 
operation,  treat  the  diabetes  by  means  of  drugs  and  diet. 
If  amputation  is  refused  or  if  the  gangrene  is  not  upon  an 
extremity,  treat  the  gangrenous  area  by  hot  antiseptic 
fomentations,  the  daily  removal  of  portions  of  dead  tissue, 
the  admmistration  of  antidiabetic  drugs,  and  the  use  of  suitable 
articles  of  diet.  Never  fail  to  examine  the  urine  in  every  case 
of  gangrene,  for  diabetes  might  be  present  when  it  had  not 
been  suspected.  Surgical  operations  upon  diabetics  are,  of 
course,  very  dangerous,  and  are  only  advised  in  emergencies 
because  the  wound  is  apt  to  slough  and  coma  may  arise' 

Gangrene  from  ergotism  is  a  peripheral  dry  gangrene 
arismg  from  tonic  vascular  contraction  produced  by  the 
ergot  m  bread  made  from   diseased  rye.     The  gangrene  is 

1  See  the  convincing  article  of  Charles  A.  Powers,  in  Atner.  /ournal  of  Med 
•yc?/?«(rfj,  Nov.  II,  1892.  J         <■<■. 

11 


1 62      MORTIFICATION,    GANGRENE,    OR   SPHACELUS. 

preceded  by  anesthesia,  muscular  cramp,  tingling  pains, 
itching,  and  "  gradual  blood-stasis  in  certain  vascular  areas  " 
(Osier).  This  form  of  gangrene  occurs  in  epidemics  where 
rye-bread  is  largely  used,  but  is  very  rare  in  the  United 
States.  It  usually  affects  the  fingers  or  toes,  but  may  in- 
volve an  entire  limb,  and  may  be  symmetrical.  In  acute 
cases  death  occurs  in  from  seven  to  ten  days.'  In  severe 
chronic  cases  await  a  line  of  demarcation  and  then  amputate. 
In  superficial  cases  dress  with  hot  antiseptic  fomentations 
and  elevate  the  part,  and  every  day  take  scissors  and  forceps 
and  remove  the  loose  crusts. 

Gangrene  from  Frost-bite. — Frost-bite  is  most  common 
in  the  fingers,  toes,  nose,  and  ears,  but  the  genital  organs, 
the  cheeks,  the  chin,  the  feet  and  legs,  and  the  hands  and 
arms  may  be  attacked.  Cold  causes  a  primary  contraction 
of  the  vessels  and  pallor  and  numbness  of  the  part.  After 
reaction  the  vessels  dilate,  the  part  reddens  and  swells,  and 
a  burning  sensation  or  actual  pain  is  experienced.  In  a 
trivial  frost-bite  the  swelling  and  redness  usually  disappear 
after  a  few  days,  but  in  some  cases  the  redness  is  permanent, 
and  in  many  cases  the  redness  returns  under  the  influence 
of  slight  cold  (see  Chilblains). 

In  a  more  severe  frost-bite  the  affected  part  becomes 
purple  and  covered  with  vesicles,  and  gangrene  may  or  may 
not  follow.  When  parts  have  been  badly  frozen  the  periph- 
eral portions  dry  up.  The  parts  are  deprived  of  all  blood 
because  of  contraction  of  the  vessels  and  because  plasma 
coagulates  at  a  few  degrees  above  freezing.  Cold  dis- 
organizes the  blood,  breaking  up  white  corpuscles  with  the 
liberation  of  fibrin-ferment  and  the  subsequent  coagulation 
of  plasma,  and  destroying  red  corpuscles  with  the  lib- 
eration of  hemoglobin.  The  thrombosis  which  is  estab- 
lished prevents  circulation,  and  the  tissue-cells  are  damaged 
beyond  repair.  The  parts  are  bloodless  and  anesthetic,  and 
a  line  of  demarcation  forms.  Hence  we  note  that  severe 
frost-bite  causes  dry  gangrene.  If  a  part  which  is  not  so 
badly  frozen  is  brought  suddenly  into  a  warm  atmosphere, 
hyperemia  takes  place  when  the  blood  runs  into  the 
frosted  tissues,  blebs  form,  and  moist  gangrene  may  result. 
Areas  of  superficial  gangrene  are  not  uncommon.  A  frost- 
bite in  which  the  skin  is  livid  and  not  as  }^et  gangrenous 
should  be  treated  by  frictions  with  snow  or  rubbing  with  towels 
soaked  in  iced  water.  As  the  skin  becomes  warmer  and 
congestion  disappears  the  part  should  be  wrapped  in  cotton- 

1  Pick,  in  Heath's  Surgical  Dictionary. 


SLOUGHING. 


163 


wool.  A  sufferer  from  frost-bite  should  not  suddenly  be 
brought  into  a  warm  room.  When  ganijrene  follows,  if  only 
small  areas  be  involved,  allow  the  dead  part  to  come  away 
spontaneously,  applying  in  the  meanwhile  hot  antiseptic 
fomentations.'  If  separation  be  delayed  by  cartilage,  liga- 
ment, or  bone,  cut  through  the  retaining  structure.  If  ampu- 
tation becomes  necessary,  await  a  line  of  demarcation,  as  it 
is  not  possible  to  be  certain  how  high  tissue-damage  extends, 
and  to  amputate  through  devitalized  parts  would  mean 
renewed  gangrene. 

Noma,  or  cancrum  oris,  is  a  condition  beginning  as  a 
slou<^^hing  ulcer  on  the  gums  or  cheeks  ;  it  produces  throm- 
bosis and  gangrene.  It  affects  young  children  who  live 
amid  filth  and  squalor  or  who  are  convalescing  from  acute 
fevers.  This  disease  may  destroy  large  portions  of  the 
cheeks  and  jaws.  The  constitu- 
tional symptoms  are  diarrhea,  fever, 
and  great  exhaustion.  Death  is  the 
usual  result,  due  frequently  to  septic 
bronchopneumonia  (Bowlby).  Lin- 
gard  has  found  a  bacillus  which  he 
believes  is  causative  of  noma,  but 
most  observers  consider  pus  organ- 
isms as  causative. 

The  treatment  of  noma  consists 
in  destruction  of  the  diseased  tissue 
by  nitric  acid  or  the  actual  cautery, 
the  use,  locally  and  often,  of  peroxid 
of  hydrogen  and  antiseptic  v\'ashes, 
and,  internally,  the  employment  of 
nutritious  food,  stimulants,  and  ton- 
ics. After  arrest  of  the  gangrene  a 
plastic  operation  may  be  required. 

Sloughing  is  a  process  by  which 
visible  portions  of  dead  tissue  are 
separated.  These  visible  portions 
are  called  "sloughs;"  if  they  were 
large,  they  w^ould  be  called  "  gan- 
grenous masses."  A  large  septic 
slough  is  a  gangrenous  mass  ;  a 
small  gangrenous  mass  is  a  slough; 
there  is  no  difference  in  the  process, 

which  corresponds  to  the  formation  of  a  line  of  demarcation. 
Sloughing  requires  thorough  and  frequent  irrigation  with  an 
antiseptic  fluid,  removal  of  the  sloughs,  and  antiseptic  treat- 


li^ 


Fig.  49. — Improvised  apparatus  for 
the  irrigation  of  a  wound. 


164      MORTIFICATION,    GANGRENE,    OR   SPHACELUS. 

ment.  An  irrigator  can  be  improvised  from  an  ordinary- 
bottle  (Fig.  49).  Antiseptic  fomentations  are  applied  until 
granulation  is  well  advanced.  In  some  cases  continuous 
irrigation  with  a  hot  antiseptic  fluid  is  useful ;  in  other 
cases  continued  immersion  in  a  hot  antiseptic  solution  is 
employed. 

Phagedena  is  a  process  (most  common  in  a  venereal 
sore)  in  which  the  surrounding  tissues  are  rapidly  eaten  up, 
the  sore  becoming  jagged  and  irregular,  with  a  sloughy  base 
and  thin  edges  ;  the  discharge  becoming  thin  and  reddish, 
and  the  encircling  tissues  becoming  deeply  congested.  This 
ulcer  has  no  tendency  to  heal.  It  is  due  to  a  specific  poison 
which  has  not  yet  been  isolated.  Noma  vidvcB  is  a  form  of 
phagedena  which  attacks  the  genitals  of  little  girls  who  are 
unhealthy,  dirty,  or  convalescent  from  a  specific  fever. 

The  treatment  of  phagedena  consists  in  repeated  touch- 
ing with  tincture  of  chlorid  of  iron  and  the  local  use  of 
iodoform,  the  employment  of  continued  irrigation  or  immer- 
sion in  hot  antiseptic  fluids,  or  the  application  of  the  cautery, 
chemical  or  actual.  After  using  the  cautery  the  part  is 
dressed  with  hot  antiseptic  fomentations.  Whatever  else  is 
done,  tonics,  stimulants,  and  nutritious  diet  must  be  given. 

Decubitus,  Decubital  Gangrene,  or  Bed-sore. — A 
bed-sore  is  the  result  of  local  failure  of  nutrition  in  a  person 
whose  tissues  are  in  a  state  of  low  vitality  from  age,  disease, 
or  from  injury.  The  arterial  condition  of  the  aged  favors  the 
development  of  bed-sores.  Such  sores  are  due  to  pressure, 
aided  it  may  be  by  some  slight  injury  or  by  the  irritation  of 
urine,  feces,  sweat,  crumbs  or  other  foreign  bodies  in  the  bed 
or  by  wrinkling  of  the  sheets.  The  pressure  destroys  vas- 
cular tone,  stasis  results,  thrombosis  occurs,  and  gangrene 
follows.  In  some  cases,  after  pressure  is  removed  there  are 
stasis,  vesication,  suppuration,  and  the  formation  of  an  ugly 
ulcer,  surrounded  by  a  zone  of  swelling  and  hyperemia. 
These  ordinary  pressure-sores  arise  like  splint-sores  due  to 
the  pressure  of  a  splint  upon  the  tissues  over  a  bony  promi- 
nence. They  occur  over  the  heels,  elbows,  scapulae,  tro- 
chanters, sacrum,  and  nucha.  The  pressure  interferes  with 
the  blood-supply,  the  weakened  tissues  inflame,  vesication 
occurs,  sloughs  form,  and  an  ugly  ulcer  is  exposed.  When 
a  bed-sore  is  about  to  form  the  skin  becomes  red  and 
edematous.  Pressure  with  the  finger  drives  the  color  out 
rather  slowly.  The  color  becomes  purple  or  black,  a  slough 
forms  and  separates,  and  a  large,  irregular,  foul  cavity  is 
exposed.     The    discharge    is    profuse    and    offensive.     The 


DECUBITAL    GAXGREXE,    OR   BED-SORE.  1 65 

parts  about  are  swollen  and  red.  If  the  sore  is  not  upon  an 
anesthetic  part,  much  suffering  is  produced  by  it.  Bed- 
sores are  most  common  in  paralyzed  parts  ;  such  parts  are 
anesthetic,  and  injurious  pressure  is  not  painful  and  does  not 
attract  attention,  and  in  such  parts  there  is  vaso-motor 
paresis. 

The  acute  bed-sores  of  Charcot  are  seen  during  certain  dis- 
eases and  after  some  injuries  of  the  nervous  system.  These 
sores  are  usual  over  the  sacrum  in  acute  myelitis,  and  may 
appear  in  four  or  fi\e  days  after  the  beginning  of  a  disease 
or  the  infliction  of  an  injury.  The  surgeon  sees  acute  bed- 
sores upon  the  buttock  of  the  parah-zed  side  after  brain- 
injuries,  and  over  the  sacrum  in  spinal  injuries.  Some  be- 
lieve these  sores  are  due  to  vaso-motor  disorder ;  but  others, 
notably  Charcot,  attribute  them  to  disturbance  of  the  trophic 
nerves  or  centers. 

Treatment  of  Bed-sores. — The  "  ounce  of  prevention  " 
is  here  invaluable.  From  time  to  time,  if  possible,  alter  the 
position  of  the  patient,  keep  him  clean,  maintain  the  blood- 
distribution  to  the  skin  by  frequent  rubbing  with  alcohol 
and  a  towel,  keep  the  sheet  clean  and  smooth,  and  in  some 
situations  use  a  ring-shaped  air-cushion  to  keep  pressure 
from  the  part.  When  congestion  appears  (paratrimma,  or 
beginning  sore),  at  once  use  an  air-cushion  or  a  water-bed 
and  redouble  the  care  to  frequently  change  the  position  of 
the  patient.  Not  only  protect,  but  also  harden,  the  skin. 
Wash  th^  part  twice  daily  and  apply  spirits  of  camphor  or 
glycerol  of  tannin  ;  or  rub  with  salt  and  whiskey  (.^ij  to  Oj) ; 
or  apply  a  mixture  of  5ss  of  powdered  alum,  f.5ij  of  tincture 
of  camphor,  and  the  whites  of  four  eggs ;  or  paint  with 
corrosive  sublimate  and  alcohol  (gr.  ij  to  5J) ;  or  apply  tan- 
nate  of  lead  or  equal  parts  of  oil  of  copaiba  and  castor  oil ;  or 
paint  on  a  protective  coat  of  flexible  collodion. 

When  the  skin  seems  on  the  verge  of  breaking,  paint  it 
with  a  solution  of  nitrate  of  silver  (gr.  xx  to  5J).  When 
the  skin  breaks,  a  good  plan  of  treatment  is  to  touch  once 
a  day  with  sih-er  solution  (gr.  x  to  5J)  and  cover  with  zinc- 
ichthyol  gelatin.  \\'e  can  wash  the  sores  daily  with  i  :  2000 
corrosive-sublimate  solution,  dust  with  iodoform,  and  cover 
with  soap  plaster,  with  lint  spread  Avith  zinc  ointment,  or  with 
dry  aseptic  gauze.  When  sloughs  form,  cut  most  of  them  off 
with  scissors  after  cleaning  the  parts,  slit  up  sinuses,  and  use 
antiseptic  fomentations.  In  sloughing  Dupuytren  employed 
pieces  of  lint  wet  with  lime-juice  and  dusted  the  sore  with 
cinchona  and  charcoal.     In  obstinate  cases  use  the  continu- 


1 66    mortification;  gangrene,  or  sphacelus. 

ous  hot  bath  or  the  ice  poultice.  When  the  sloughs  sepa- 
rate, dress  antiseptically  or  with  equal  parts  of  resin  cerate 
and  balsam  of  Peru.  If  healing  is  slow,  touch  occasionally 
with  silver  solution  (gr.  x  to  5J).  Bed-sores,  being  expressive 
of  lowered  vitality,  demand  that  the  patient  shall  be  stimu- 
lated, shall  be  well  nourished,  and  shall  sleep  soundly. 

I/Udwig'S  Kri^vaSi  {^Angina  Liuiovici). — This  disease  is  a 
streptococcus  infection  about  the  submaxillary  gland  and 
the  cellular  tissue  beneath  the  mucous  membrane  of  the 
floor  of  the  mouth  and  of , the  upper  portion  of  the  neck. 
The  inflammation  eventuates  in  suppuration  and  gangrene. 
The  disease  arises  as  a  painful  swelling  in  the  neighborhood 
of  the  submaxillary  gland.  The  swelling  rapidly  increases, 
involves  the  neck  and  floor  of  the  mouth,  causes  great  dif- 
ficulty in  opening  the  mouth  and  in  swallowing,  and  may 
lead  to  edema  of  the  glottis.^  The  constitutional  symptoms 
are  those  of  septicemia  or  pyemia.  The  disease  may  arise 
in  an  apparently  healthy  man  or  during  or  after  an  infectious 
fever. 

Treatment. — At  once  incise  below  the  body  of  the  lower 
jaw,  open  the  submaxillary  space,  cut  away  gangrenous  tis- 
sue, paint  with  pure  carbolic  acid,  pack  with  iodoform  gauze, 
and  apply  hot  antiseptic  fomentations.  The  constitutional 
treatment  is  that  of  septicemia. 

Postfebrile  Gangrene. — Dry  or  moist  gangrene  may 
follow  any  fever,  but  is  most  frequent  after  typhoid  (may 
follow  typhus,  influenza,  measles,  scarlet  fever,  etc.).  Keen 
tells  us  that  the  gangrene  resulting  from  arterial  obstruction 
is  apt  to  be  dry,  and  that  from  venous  obstruction  is  usually 
moist.  The  same  observer  has  collected  203  cases.-  It  is 
most  usual  in  the  lower  extremities,  but  may  appear  in  the 
upper  extremities,  cheeks,  ears,  nose,  genitals,  lungs,  etc. 
Some  writers  have  assigned  as  the  cause  weakness  of  cardiac 
action,  but  most  observers  believe  an  obstructing  clot  is  the 
usual  cause.  This  clot  may  come  from  the  heart,  but  is 
usually  secondary  to  endarteritis  due  to  the  action  of  the 
toxins  of  the  bacilli  of  the  specific  fever.  Keen  show^s  that 
in  some  cases  gangrene  is  due  to  obstruction  of  peripheral 
vessels  and  not  of  a  main  trunk.  Gangrene  most  often 
appears  late  in  the  course  of  the  fever,  and  may  begin  as 
early  as  the  fourteenth  day  of  the  typhoid,  but  may  arise  far 
into  convalescence.  In  rare  cases  gangrene  arises  after 
thrombophlebitis.    In  the  course  of  a  continued  fever  frequent 

1  Tillmann's  Text-book  of  Surgery,  translated  by  B.  T.  Tilton. 

^  Keen,  on  the  Surgical  Complications  and  Sequels  of  Typhoid  Fever. 


THROMBOSIS. 


167 


examinations  should  be  made  to  see  that  gangrene  is  not 
arising.  Keen  says  particular  examination  from  time  to  time 
should  be  made  of  the  lower  extremities,  and  in  young:  sirls, 
of  the  genitals.  If  gangrene  arises  in  an  extremity,  appl)' 
antiseptic  dressings,  wait  for  a  line  of  demarcation,  and  then 
amputate.  If  gangrene  occurs  in  other  regions,  remove  the 
dead  tissue  aiul  eniplo\-  hut  antiseptic  fomentations. 

Rules  when  to  Amputate  for  Gangrene. — In  dry 
gangrene,  due  to  obstruction  of  a  non-diseased  arter\-,  wait 
for  a  line  of  demarcation.  In  senile  gangrene,  if  it  affect 
only  one  or  two  toes,  let  the  dead  parts  be  cast  off  sponta- 
neously. If  a  greater  area  is  involved  or  the  process 
spreads,  amputate  above  the  knee  without  waiting  for  the 
line.  In  orduiaiy  moist  gangrene  wait  for  a  line  of  demar- 
cation. In  traumatic  sprcadi)ig  gangrene  amputate  at  once. 
In  hospital  gangrene  and  in  Raynajid's  gangrene  wait  for  a 
line  of  demarcation.  In  diabetic  gangrene  amputate  at  once, 
high  up.  In  ergot  gangrene,  in  postfebrile  gangrene,  and  in 
frost  gangrene  wait  for  a  line  of  demarcation. 


IX.  THR0MB05I5  AND  EMB0LI5M. 

Tliroinbosis  is  the  antemortem  coagulation  of  blood  in 
the  heart  or  in  a  vessel,  the  coagulum  remaining  at  its  point 
of  origin  and  plugging  up  the  vessel  partially  or  completely. 
The  process  is  known  as  thrombosis  ;  the  clot  is  called  the 
thrombus.  This  process  is  an  essential  part  in  the  arrest  of 
hemorrhage ;  it  occurs  in  phlebitis  and 
arteritis,  and  affords  a  frequent  basis  for 
embolism.  Thrombi  may  form  in  the 
veins,  in  the  arteries,  and  in  the  heart. 
Clotting  is  due  to  destruction  of  white 
blood-cells,  fibrin-ferment  being  set  free, 
causing  the  union  of  calcium  and  fibrin- 
ogen and  thus  forming  fibrin.  Throm- 
bosis is  more  common  in  the  veins  than 
in  the  arteries,  the  slow  blood-current 
and  the  existence  of  valves  favoring  the 
"deposit,  though  not  causing  it.  A  throm- 
bus forms  gradually,  being  deposited 
layer  by  layer,  hence  it  is  stratified  or 
laminated.  Fig.  50  shows  a  thrombus 
in  a  vein.  All  thrombi  are  either  septic 
or  aseptic,  and  they  are  also  spoken  of  as  fibrinous,  red,  he 
mostatic,  leukocytic,  etc. 


Fig.  50. — Thrombus  in  the 
saphenous  vein  (Green). 


1 68  THROMBOSIS  AND   EMBOLISM. 

Causes  of  Thrombosis. — The  essential  cause  of  all  intra- 
vascular thrombi  is  damage  to  the  endothelial  coat.  Any 
condition  which  causes  the  blood  to  contain  an  excess  of 
fibrin-forming  elements  favors  thrombosis,  in  the  sense  that 
a  slight  injury  of  the  vascular  endothelium  will  be  followed 
by  clot  formation.  Among  conditions  favoring  thrombosis 
we  must  note  particularly  slowing  of  circulation,  however 
caused.  Among  special  favoring  conditions  are  retarded 
circulation  in  tuberculosis,  influenza,  and  fevers,  the  blood 
clotting  behind  the  vein-valves  after  the  endothelium  has 
been  damaged  by  toxins ;  inflammations ;  the  pressure  of  a 
bandage  or  of  a  splint ;  varicose  veins  ;  ligation  of  a  vessel ; 
injuries  of  a  vessel;  foreign  bodies  in  a  vessel;  atheroma  in 
arteries  ;  sutures  in  a  vessel ;  certain  diseases,  such  as  gout, 
typhoid  fever,  pregnancy,  and  septic  processes ;  phlebitis 
or  arteritis  arising  in  the  vessel  or  from  extension  of  sur- 
rounding inflammation ;  and  entrance  of  specific  organ- 
isms. 

It  has  been  asserted  that  so  long  as  the  endothelium  of  a 
vessel  is  uninjured  a  clot  does  not  form.  Slowing  of  the 
blood-current  in  aseptic  conditions,  it  is  now  taught,  will 
not  cause  thrombosis.  One  of  the  functions  of  the  endo- 
thelial coat  is  to  keep  the  blood  fluid  by  preventing  corpus- 
cular disintegration.  A  thrombus  can  form  only  when  fibrin- 
ferment  is  set  free,  and  fibrin-ferment  can  be  set  free  only 
when  white  corpuscles  disintegrate.  When  moving  blood 
coagulates,  the  third  corpuscles  first  settle  out,  and  then  the 
leukocytes.  This  is  known  as  the  white  or  "  antemortem  " 
thrombus — the  clot  of  moving  blood.  Thrombi  from  moving 
blood  are  rarely  pur&  white :  they  contain  some  red  cor- 
puscles, forming  mixed  thrombi.  The  red  thrombus  plugs 
vessels  which  are  cut  across  or  ligated  ;  it  also  occurs  in 
septic  processes,  and  is  formed  after  death.  A  thrombus 
soon  undergoes  a  change.  An  aseptic  clot  is  usually  "  or- 
ganized," that  is,  absorbed  and  replaced  by  fibrous  tissue. 
The  walls  of  the  injured  vessel  become  filled  with  leukocytes, 
leukocytes  invade  the  clot,  the  endothelium  proliferates,  and 
the  young  cells  follow  the  colonies  of  leukocytes  into  the 
thrombus.  The  thrombus  is  gradually  removed  by  leuko- 
cytes and  replaced  by  fibroblasts,  the  new  tissue  is  vascu- 
larized and  becomes  granulation-tissue,  the  granulation-tissue 
is  converted  into  fibrous  tissue,  and  the  fibrous  tissue  con- 
tracts. In  some  rare  instances  a  thrombus  is  implanted  on  the 
wall  of  the  vessel,  and  the  tube  is  not  permanently  occluded. 
In  most  instances  the  vessel  is  converted  into  a  narrow  cord  of 


THROMBOSIS.  1 69 

fibrous  tissue.  A  thrombus  may  degenerate  and  break  down 
(fatty  degeneration),  giving  rise  to  em- 
boli or  undergoing  calcification.  A  cal- 
cified thrombus  in  a  vein  is  known  as  a 
phlebolith.  An  infected  thrombus  may 
undergo  liquefaction,  infective  emboli 
being  set  free  (Fig.  51).  A  thrombus 
in  an  artery  is  apt  to  extend  to  the  first 
collateral  branch,    but    does    not  pass  .x 

higher,    the    blood-current     into     the        ^^^/ 
branch   preventing    further    extension.  "^j/ 

Remember  this  fact  when  an  artery  is 
cut  near  a  large  branch.     If  we  simply     ^  t  <■  '   ^  , 

,  111  Ml    1  r\G.  51. — Infected  thrombus 

tie  the  artery,  such  a  short  clot  will  be         ofa  vein  (schematic). 
formed    that    the    vessel    will    not    be 

obliterated.  Tie  not  only  the  artery,  but  also  the  branch. 
A  clot  in  a  vein  may  extend  a  long  distance.  The  author 
has  seen  in  a  post-mortem  examination  a  venous  thrombus 
reaching  from  the  ankle  to  the  vena  cava.  A  spreading 
clot  of  this  sort  is  known  as  a  propagated  thrombus. 

Symptoms. — The  symptoms  are  dependent  on  the  seat 
of  the  obstruction.  An  organ  or  a  part  of  an  organ  may 
exhibit  functional  aberration.  The  local  signs  in  a  vessel 
accessible  to  touch  or  sight  are  the  presence  of  a  clot ;  if  it 
be  in  an  artery,  anemia  and  the  absence  of  pulse  below  the 
clot ;  if  it  be  a  vein,  swelling  and  edema  below  it.  There  is 
usually  pain  at  the  seat  of  trouble,  and  anesthesia  below  it. 
Moist  gangrene  may  follow  venous  thrombosis,  and  dry  gan- 
grene, arterial  thrombosis.  Thrombosis  of  the  mesenteric 
vein  is  followed  by  gangrene  of  the  bowel.  Thrombophlebi- 
tis is  a  spreading  inflammation  of  a  vein  in  which  a  septic 
thrombus  forms.  We  see  this  condition  sometimes  in  the 
lateral  sinus  of  the  brain  as  a  result  of  suppuration  in  the 
middle  ear;  in  any  of  the  cerebral  sinuses  after  infected 
compound  fracture  of  the  skull ;  and  in  the  uterine  veins  in 
puerperal  sepsis.  Infective  thrombophlebitis  is  an  early 
step  in  pyemia.  Thrombo-arteritis  is  a  spreading  inflamma- 
tion of  an  artery  in  which  a  septic  thrombus  forms  or  in 
which  a  septic  embolus  lodges.  It  occasionally  attacks  an 
aneurysmal  sac. 

Treatment. — If  a  thrombus  forms  in  a  large  vessel  of  a 
limb,  raise  the  limb  a  few  inches  from  the  bed,  keep  it  per- 
fectly quiet  to  avoid  detachment  of  fragments  (emboli),  apply 
a  bandage  from  the  toes  up,  and  place  hot  bottles  around  the 
extremity.     The  great  danger  is  the  formation  of  emboli,  so 


I/O  THROMBOSIS  AND  EMBOLISM. 

movements  and  rough  handling  are  to  be  avoided.  Gangrene 
is  another  danger,  hence  favor  venous  return  and  the 
development  of  the  collateral  circulation  by  warmth,  eleva- 
tion, and  bandaging.  In  septic  thrombophlebitis,  if  the 
vessel  is  accessible,  tie  it  above  and  below  the  clot,  open 
the  vessel,  remove  the  clot,  irrigate,  and  pack  the  wound 
with  iodoform  gauze.  Internally  the  treatment  is  stimulant 
and  supporting.  Massage  is  unsafe  in  any  condition  of 
thrombosis,  and  is  particularly  dangerous  in  septic  throm- 
bosis. In  thrombo-arteritis  treat  as  in  thrombophlebitis.  If 
gangrene   follows   thrombosis,    treat  as  previously    directed 

(P-  154)- 

Kmbolism  signifies  vascular  plugging  by  a  foreign  body 
(usually  a  blood-clot)  which  has  been  brought  from  a  dis- 
tance. Emboli  may  arise  either  in  the  venous  or  in  the 
arterial  system,  .but  lodge  only  in  an  artery,  in  capillaries, 
or  in  the  veins  of  the  liver.  The  initial  thrombus  may  form 
upon  a  diseased  heart-valve  or  in  a  vein.  It  may  be  composed 
of  fat,  micro-organisms,  air,  or  a  portion  of  a  tumor.  An 
embolus  is  arrested  when  it  reaches  a  vessel  whose  diameter 
is  less  than  its  own.  It  is  usually  caught  just  above  a  bifur- 
cation. When  an  embolus  lodges,  it  at  once  partially  or 
entirely  obstructs  the  circulation,  and  increases  in  size  by 
thrombosis.  A  non-septic  embolus  usually  "  organizes,"  and, 
as  described  on  page  i68,  is  replaced  by  fibrous  tissue.  A 
soft  embolus  may  disintegrate  and  permit  of  re-establishment 
of  the  circulation.  An  embolus  may  cause  an  aneurysm. 
A  septic  embolus  breaks  down,  forms  a  metastatic  abscess, 
and  sends  other  emboli  onward.  Fig.  52  shows  an  impacted 
embolus. 

An  embolus  is  more  serious  than  a  thrombus :  it  causes 
sudden  plugging,  which  makes  dangerous  anemia  inevitable, 
and  it  will  produce  gangrene  if  the  collateral  circulation  fails. 
Embolism  of  the  mesenteric  artery  causes  necrosis  of  the 
intestine.  In  organs  with  terminal  arteries  (spleen,  kidney, 
brain,  and  lung)  there  is  no  collateral  circulation  and 
embolism  causes  infarction.  The  embolus  produces  an  area 
of  anemia  ;  the  removal  of  all  propulsion  upon  the  venous 
blood  causes  it  to  flow  back  and  stagnate,  and  vascular  ele- 
ments exude,  forming  a  wedge-shaped  area  of  red  tissue,  the 
embolus  being  the  apex  of  the  wedge.  This  is  known  as  the 
"  red  infarction,"  and  is  often  seen  in  the  lung  (Fig.  53).  The 
white  infarction,  seen  in  the  brain  and  kidney,  is  not  due  to 
retrogression  of  venous  blood,  but  is  due  to  anemia  and 
resulting    coagulation-necrosis.     A    septic    embolus    causes 


EMBOLISM. 


171 


septic  thrombosis  and  a  septic  infarction,  and  a  septic  infarc- 
tion is  followed  by  suppuration  and  the  production  of  a 
pyemic  abscess.  If  emboli  come  from  a  thrombus  in  one 
of  the  veins  of  the  pulmonar}-  circulation,  they  lodge  in  the 
lungs,  and  rarely,  though  occasionally,  pass  through.  Em- 
boli formed  in  vessels  of  the  systemic  circulation  lodge  most 
often  in  the  lungs,  brain,  kidney,  or  spleen  (Nancrede). 
Emboli  passing  into  the  portal  vein  lodge  in  the  liver. 

Sym.ptonis. — The    s}'mptoms    depend    upon    the    organ 
involved.     They  are  sudden  in  onset,  and  consist  of  loss  of 


Fig.  52. — Embolus  impacted 
at  bifurcation  of  a  branch  of  the 
pulmonar>-  artery  (Green). 


Fig.  53. — Diagram  of  a  hemorrhagic 
infarct :  a,  artery  obliterated  by  an  em- 
bolus {e)  ;  -',  vein  filled  with  a  secondary 
thrombus  (tJi)  ;  i,  center  of  infarct, 
which  is  becoming  disintegrated  ;  2,  area 
of  extravasation:  3,  area  of  collateral 
hyperemia  (O.Weber). 


function  which  ma}'  be  permanent  or  which  ma}-  be  followed 
by  inflammation,  softening  or  gangrene.  Embolism  ol  the 
cerebral  arteries  may  cause  aphasia,  paralysis,  or  coma. 
EmboHsm  of  the  pulmonar}-  arteiy  may  cause  almost  instant 
death.  Embolism  of  the  central  arter}'  of  the  retina  causes 
blindness.  EmboHsm  of  a  large  arter}'  of  a  limb  produces 
symptoms  identical  with  thrombus,  except  more  sudden  and 
decided.  Embolism  of  the  superior  mesenteric  arteiy  pro- 
duces symptoms  similar  to  those  caused  by  acute  intestinal 
obstruction. 

Treatment. — The  treatment  oi  aseptic  embolism  depends 
upon  the  part  involved.  In  a  limb,  keep  the  part  warm  in 
order  to  stimulate  the  collateral  circulation,  elevate  se\-eral 
inches  from  the  bed.  apply  a  bandage  lightly  from  the  periph- 
er}',  and  insist  on  perfect  quiet.  Massage  is  unsafe.  If  gan- 
grene ensues,  await  a  line  of  demarcation  and  amputate.  In 
septic  thrombo-arteritis  in  an  accessible  region  it  would  be 
good  surger}^  to  act  as  in  septic  thrombophlebitis.     After  an 


1/2  THROMBOSIS  AND   EMBOLISM. 

operation  upon  veins  (as  the  operation  for  varicocele  or  for 
hemorrhoids),  after  a  cutting  operation,  and  after  fracture, 
avoid  as  much  as  possible  movements  or  handling,  as  frag- 
ments of  thrombus  may  be  detached.  Operations  upon  the 
rectum  may  be  followed  by  hepatic  embolism  and  abscess  of 
the  liver. 

Kat-embolism  is  an  accumulation  in  the  capillaries  of 
liquid  fat  after  injuries  of  adipose  tissue,  high  tension  forcing 
the  fat  into  the  open  mouths  of  veins.  Some  little  fat  may 
get  into  the  blood  by  means  of  the  lymphatics.  Fat-em- 
bolism occasionally  arises  during  osteomyelitis,  after  extensiv^e 
bruises,  crushes,  or  lacerations,  and  after  amputations,  fract- 
ures, resections,  or  rupture  of  the  liver.^  This  fluid  fat  ac- 
cumulates especially  in  the  capillaries  of  the  lungs  and  brain. 

Symptoms. — The  symptoms  are  those  of  edema  of  the 
lungs  and  exhaustion,  often  with  coma  or  delirium,  and  some- 
times, in  the  beginning,  are  wrongly  thought  to  be  due  to  shock. 
There  are  restlessness,  dyspnea,  rapid  pulse  and  respiration, 
normal  or  subnormal  temperature,  and  cyanosis.  If  pulmo- 
nary edema  becomes  marked,  the  patient  spits  up  a  bloody 
froth.  If  life  is  prolonged  a  day  or  two,  oil  is  found  in  the  urine. 
Small  amounts  of  oil  may  be  found  in  the  urine  after  serious 
injuries  or  operations  when  no  symptoms  of  embolism  exi.st. 
Nevertheless,  the  presence  of  the  oil  is  always  an  ominous 
sign,  and  is  often  a  warning.  These  symptoms  ne\'er  occur 
until  at  least  twelve  hours  after  the  accident,  and  rarely 
before  the  third  day.  The  symptoms  occur  at  a  later  period 
than  those  of  shock,  and  at  an  earlier  period  than  those  of 
ordinary  emboUsm  of  the  lung.  If  some  of  the  oil  is  forced 
through  the  vessels  of  the  lung,  it  will  lodge  in  other  regions 
and  produce  other  symptoms.  Oil  may  appear  in  the  urine 
as  above  stated.  Urinary  suppression  may  occur.  Delirium 
may  arise  or  the  patient  may  pass  into  coma.  Severe  cases 
of  fat-embolism  are  commonly  fatal ;  milder  cases  are  often 
recovered  from. 

Treatment. — The  treatment  consists  in  the  administration 
of  stimulants,  such  as  strychnin,  alcohol,  and  carbonate  of 
ammonium,  the  use  of  external  heat ;  the  use  of  oxygen  by 
inhalation ;  and  the  administration  of  diuretics  and  of  nitro- 
glycerin hypodermatically.  Artificial  respiration  may  tide  a 
patient  over  a  crisis.  If  an  external  wound  exists,  the  drainage 
must  be  free,  and  the  damaged  part  should  be  thoroughly 
immobilized.  In  order  to  prevent  fat-embolism  after  a 
severe  injury  insist  on  rest.     Massage  used  early  after  some 

^  G.  H.  Makins,  in  Heath's  Dictionary. 


SEPTICEMIA.  173 

injuries  is  dangerous,  as  it  may  force  fluid  fat  into  the  vessels. 
When  a  se\-ere  contusion  causes  the  formation  of  a  large 
cavity  filled  with  blood  Groube  advises  incision,  to  lessen 
the  danger  o{  fat-embolism.^ 

Air-embolism. — Air  ma}-  enter  a  vein  during  a  surgical 
operation  or  it  may  be  injected  accidentalh'  while  giving  a 
h}-podermatic  injection,  hypodermoch-sis,  or  a  saline  infusion 
into  a  vein.  It  is  veiy  rarely  that  an}-  s}'mptoms  follow.  It 
w^as  long  thought  that  such  an  accident  must  be  extremeh- 
dangerous.  Dr.  Hare's  experiments  indicate  that  quantities 
of  air  ma}-  be  injected  into  the  \-eins  of  a  dog  without 
apparent  harm.  The  entr}-  of  a  small  amount  of  air  into  the 
veins  of  a  human  being  will  not  be  apt  to  induce  dangerous 
symptoms,  but  it  ma}-  be  fatal.  The  more  rapid!}-  it  is  intro- 
duced and  the  greater  the  amount,  the  greater  is  the  danger. 
The  manner  in  which  it  can  induce  death  is  doubtful.  Some 
maintain  that  it  causes  the  blood  in  the  right  side  of  the  heart 
to  froth,  and  thus  prevents  normal  action  of  the  valves,  the 
heart  becoming  unable  to  propel  blood  through  the  lungs. 
If  a  surgeon  divides  a  large  vein,  air  mav  be  sucked  in.  and 
there  is  particular  danger  of  such  an  accident  if  a  vein  at 
the  root  of  the  neck  or  a  cerebral  sinus  is  torn  or  incised.  If 
such  an  accident  happens,  there  is  a  sucking  sound  and  serious 
symptoms  ma}-  or  ma}-  not  follow.  If  serious  s}-mptoms  are 
produced,  the}'  arise  suddenl}-.  and  consist  of  extreme  failure 
of  circulation,  gasping  for  air,  convulsions,  and  possibh'  death. 

Treatment. — Compress  the  vein  wdth  the  finger  and  clamp 
it  quickl}-.  Suspend  the  anesthetic,  lower  the  head,  employ 
artificial  respiration  and  inhalation  of  oxygen,  and  ^\\c 
str}-chnin  hypodermaticall}-. 

X.  SEPTICEMIA  AND   PYEMIA. 

Septicemia,  or  sepsis,  is  a  febrile  malad}'  due  to  the  in- 
troduction into  the  blood  of  pyogenic  organisms  or  the 
products  of  p}-ogenic  organisms  or  saprophytic  bacteria. 
There  is  no  one  special  causative  organism,  and  an}-  microbe 
which  produces  inflammator}-  and  febrile  products  ma}-  cause 
it.  Either  streptococci  or  staphylococci  may  be  present. 
Septicemia  arises  by  absorption  of  septic  matter  b}"  the  h-m- 
phatics.  Clinically  we  make  two  forms  of  septicemia:  (i) 
sapremia.  septic  or  putrid  intoxication  :  and  (2)  septic  infec- 
tion, true  or  progressive  septicemia.  In  these  conditions 
the   area   of  infection  is   usual!}-  discovered  by  the  surgeon; 

'  Rev.  de  Chir.,  July,  1895. 


174  SEPTICEMIA    AND   PYEMIA. 

but  when   it   cannot  be  located  the  disease  is  called  b\'  the 
Germans  cryptogenetic  septicemia. 

Sapreraia,  septic  or  putrid  intoxication,  is  due  to  the 
absorption  of  poisonous  ptomains  from  a  putrefying  area.  The 
bacteria  do  not  enter  the  blood,  but  their  toxins  do,  and,  as 
these  toxins  are  active  poisons,  the  condition  is  comparable 
to  poisoning  by  successive  alkaloidal  injections,  the  symptoms 
and  prognosis  depending  upon  the  dose.  Not  unusually 
there  is  absorption  not  only  of  the  toxins  of  saprophytic 
bacteria,  but  also  the  toxins  of  pyogenic  micro-organisms. 
Even  if  some  of  the  organisms  enter  the  blood,  they  do  not 
multiply  in  this  fluid.  Slight  symptoms  and  recovery  follow 
a  small  dose  ;  grave  symptoms  and  death  follow  a  large  one. 
The  poison  does  not  multiply  in  the  blood,  and  a  drop  of  the 
blood  of  a  person  laboring  under  putrid  intoxication  will  not 
produce  the  disease  when  introduced  into  the  blood  of  a  well 
person  ;  in  other  words,  the  disease  is  not  infective.  Con- 
siderable putrid  material  must  be  absorbed  to  cause  sapremia. 
What  is  known  as  surgical  fever  is  due  to  the  absorption  of  a 
small  amount  of  putrid  or  fermented  wound-fluid,  and  is  in 
reality  a  mild  form  of  sapremia.  If  sapremia  arises,  it  does  so 
soon  after  the  infliction  of  a  wound,  and  after  a  large  rather 
than  small  wound,  when  a  large  amount  of  wound-fluid  is  pent 
up  under  pressure.  It  may  follow  labor  where  putrid  fluid 
is  retained  in  the  womb,  may  follow  an  injur\'  of  or  an  opera- 
tion upon  a  joint,  may  follow  amputation  where  decomposing 
blood-clot  or  wound-fluid  is  pent  up  within  the  flaps,  or  may 
ensue  upon  an  abdominal  operation  or  injury.  In  sapremia 
there  always  exist  a  considerable  absorbing  surface  and  a 
large  amount  of  dead  matter  which  has  become  putrid. 
Roswell  Park  points  out  ^  that  sapremia  arises  from  putre- 
faction of  a  blood-clot  or  wound-fluids  which  are  re- 
tained like  foreign  bodies  in  the  tissues,  and  does  not  arise 
from  putrefaction  of  the  tissues  themselves.  He  speaks  of 
the  condition  as  due  to  the  absorption  of  poison  from  a 
"  putrid  suppositor}' ."  Sapremia  will  not  occur  after  granu- 
lations form.  The  term  putrefaction  is  used  because  this  is 
the  usual  change,  but  any  fermentative  organism  may  cause 
the  disorder.  Sapremia  is  a  malignant  form  of  surgical  fever, 
and  its  existence  means  an  ill-drained  wound,  and  a  fermenting 
and  probably  putrid  collection  of  blood-clot  or  wound-fluid. 
In  sapremia  there  is  congestion  of  the  stomach,  intestines, 
and  other  abdominal  viscera,  particularly  the  kidneys,  and 
also  of  the  brain.     Numbers  of  red  blood-cells  disintegrate. 

^  Treatise  on  Surgeiy  by  American  Authors. 


SEPTICEMIA.  175 

Symptoms. — The  patient  often  seems  to  react  incompletely 
from  the  injur}-,  he  feels   miserable,  complains  of  headache, 
nausea,  and  pain  in  the  back  and  limbs,  or,  he  may  react  and 
in  a  day  or  two  develop  this  condition  of  malaise.     In  some 
cases  an  aseptic    fever  is  directly    succeeded    by    sapremia. 
In  most  cases  of  sapremia,  between  twent}'-four   hours   and 
two   or  three  days   after   labor,  after  an  injur}-,  or  after   an 
operation,  there  is  a  chill,  or  at  least  a  chilly  sensation,  though 
in  some  cases  this    is    wanting.      The    temperature   rapidly 
rises  to  103°  F.  or  e^-en  more.   There  are  severe  headache,  dr}^ 
and  coated  tongue,  rapid  and  weak  pulse,  nausea  and  often 
vomiting,  diarrhea,  great  prostration,  restlessness,  muscular 
twitching,  and  active   delirium.     The  wound   is  found  to  be 
foul,  and  often  there  is  dr}-ing  up  of  wound-discharge.     There 
is  diminution  or  suppression  of  urine,  and  a  strong  tendenc}^ 
to   congestion  of  various  organs.    Jaundice   is  not  unusual. 
Blood-examination  shows  leukocytosis  and  corpuscular  dis- 
organization.    Petechial   spots    are    often    noticed    upon  the 
skin.     The}'  occur  also  upon  mucous  membranes  and  serous 
surfaces,    and    result  from   the   plugging    of   small    vessels 
with  detritus  of  broken-down  red  corpuscles  and  consequent 
vascular  rupture.     Great  elevation  of  temperature  often  pre- 
cedes death.     In  some  cases  the  dose   of  poison   is   so  large 
that  the  patient  passes  into  rapid  collapse  without  prehminary 
fever.     Some  cases  are  recovered  from  if  the  initial  dose  is 
not  overwhelming  and  if  additional  doses   are   not   absorbed. 
]Many  cases  die  of  exhaustion.     Some  become   linked  with 
fatal   p}-emia  or  septicemia.     The    blood    should  always  be 
examined  for  organisms  by  making  co\-er-glass  preparations. 
Treatment. — The  treatment  consists   in  at    once   draining 
and  asepticizing  the  putrid  area  and  administering  very  large 
doses  of  alcohol  and  large  medicinal  doses  of  str}-chnin  and 
digitalis.     The    patient    should    be    purged    and   diaphoresis 
favored.     The   hot  bath  is  valuable  to  cause  sweating.     The 
action  of  the  kidneys  must  be  maintained  if  possible.     Purga- 
tives, diuretics,  and  diaphoretics  aid  in   removing  the  toxin, 
and  stimulants  sustain  the  strength  of  the  patient  during  the 
elimination   of  the   poison.     Allay  vomiting  by  champagne. 
cracked  ice.  calomel,  cocain,  or  carbolic    acid  with  bismuth. 
Give  food  ever}'  three  hours.     Feed  the  patient  on  milk,  milk 
and  lime-water,    liquid    beef-peptonoids,   and    other  concen- 
trated foods.     Use   quinin  in   stimulant  doses.     Antipyretics 
are  useless.     Watch  for  any  visceral  congestion,  and  treat  it  at 
once.     The  use  of  saline  fluid  by  hypodermoclysis  or  intra- 
venous infusion  dilutes  the  poison  and  stimulates  the  heart, 


1/6  SEPTICEMIA   AND   PYEMIA. 

skin,  and  kidneys  to  activity.  Antistreptococcic  serum  is 
useless  in  sapremia. 

Septic  infection,  or  true  septicemia,  is  a  true  infective 
process.  In  sapremia  the  blood  contains  toxins  of  putrefac- 
tive organisms,  but  not  the  organisms  themselves.  In  septic 
infection  the  blood  contains  both  pyogenic  toxins  and  multi- 
plying pyogenic  organisms.  In  sapremia  the  causative  con- 
dition is  putrid  material  lodged  like  a  foreign  body  in  the 
tissues.  In  septic  infection  the  tissues  themselves  are  suppu- 
rating, and  both  bacteria  and  toxins  are  being  absorbed  by 
the  lymphatics.  Of  course,  septic  infection  may  be  associated 
with  septic  intoxication  or  may  follow  it.  In  suppurative  fever 
the  tissues  suppurate,  but  only  the  pyogenic  toxins  are  ab- 
sorbed, and  not  the  pyogenic  organisms.  In  septic  infection 
both  the  pyogenic  bacteria  and  toxins  enter  the  blood,  and 
the  bacteria  multiply  in  the  blood  and  produce  continually 
increasing  amounts  of  poison.  The  symptoms  of  sapremia 
depend  on  the  dose.  In  septic  infection  only  a  small  number 
of  organisms  may  get  into  the  blood,  but  they  multiply  enor- 
mously. The  pus  microbes  cause  true  septicemia,  and  reach 
the  blood  chiefly  through  the  lymphatics,  but  to  some  degree 
by  penetrating  the  walls  of  vessels.  A  drop  of  blood  from  a 
man  with  septic  infection  will  reproduce  the  disease  when  in- 
jected into  the  blood  of  an  animal ;  hence  the  disease  is  truly 
infective.  The  wound  in  such  cases  is  often  small,  but  may  be 
large,  and  is  commonly  punctured  or  lacerated,  and  the  dis- 
ease begins  later  after  the  infliction  of  a  wound  than  does  sapre- 
mia. No  wound  may  be  discoverable,  the  infection  having 
arisen  from  an  unrecognized  focus  of  suppuration, for  instance, 
gonorrhea,  middle-ear  disease,  caries  of  teeth,  tonsillar  sup- 
puration, appendicitis,  etc.  Septicemia  in  which  the  initial 
atrium  of  infection  is  not  discovered  is  called  cryptogenetic 
septicemia. 

The  organisms  which  are  found  in  the  blood  and  organs 
are  staphylococci  or  streptococci,  usually  both.  The  blood  is 
found  to  have  lost  much  of  its  coagulating  power ;  it  remains 
fluid  for  some  time  after  death,  and  minute  hemorrhages 
take  place  in  the  brain,  mucous  membranes,  skin,  serous  mem- 
branes, muscles,  and  various  viscera.  There  may  be  inflam- 
mation of  synovial  and  serous  membranes.  There  is  conges- 
tion of  the  gastro-intestinal  tube  and  of  the  abdominal 
viscera.  The  lymph-glands  are  larger  than  normal  and  the 
spleen  is  notably  enlarged.  The  wound  contains  numbers 
of  bacteria. 

Symptoms. — The    type  of    this    condition  is  met  with  in 


P  YEMIA. 


177 


puerperal  septicemia  or  in  an  infected  wound.  The  post- 
operative rise  may  continue  for  an  undue  time  and  septicemia 
develop.  Septicemia  may  arise  during  the  existence  or  after 
the  abatement  of  sapremia,  or  ma}-  arise  when  the  aseptic 
fever  has  passed  awa}-  and  when  there  has  been  no  putrid 
intoxication.  It  begins  in  from  four  to  seven  days  after 
labor  or  an  injur}-,  usually  with  a  chill,  which  is  followed  by 
fever,  at  first  moderate,  but  soon  becoming  high.  In  some 
cases  there  is  a  chill}-  sensation,  but  no  distinct  chill.  There 
is  alwa}-s  great  prostration  e\-en  before  the  chill.  The  fever 
presents  morning  remissions  and  evening  exacerbations,  and 
ma}-  occasionally  show  an  intermission.  When  the  remis- 
sion begins  there  is  a  copious  sweat.  As  the  case  progresses 
the  temperature  may  fluctuate,  and  it  often  rises  \eiy  high 
before  death.  The  pulse  is  small,  weak,  vei-}-  frequent,  and 
compressible.  The  tongue  is  diy  and  brown,  with  a  red  tip. 
Sordes  gather  on  the  teeth  and  gums.  \^omiting  is  frequent, 
and,  as  a  rule,  there  is  diarrhea.  Low  delirium  alternates 
with  stupor,  and  coma  is  usual  before  death.  The  great 
prostration  is  a  noticeable  and  characteristic  feature  of  the 
sufterer  from  septicemia.  There  are  subsultus  tendinum  and 
carphologia.  Toward  the  end  the  face  often  becomes  Hippo- 
cratic.  \'isceral  congestions  occur.  The  spleen  is  enlarged, 
ecch}-moses  and  petechiae  are  noted,  urinar}-  secretion  be- 
comes scant}-  or  is  suppressed,  and  the  wound  becomes  dry 
and  brown.  Blood-examination  detects  disintegration  of  red 
globules  and  marked  leukoc}-tosis.  Cover-glass  preparations 
made  from  the  blood  ma}-  disclose  pyogenic  bacteria.  When 
septicemia  arises  from  an  infected  wound,  red  lines  due  to 
lymphangitis  are  usuall}-  seen  about  it,  and  there  is  enlarge- 
ment of  related  lymphatic  glands.  In  some  cases,  however, 
the  wound  and  the  parts  about  it  look  normal. 

The  prognosis  is  bad,  and  in  some  malignant  cases  death 
occurs  within  twent}--four  hours,  but  mild  cases  often  recover. 

The  trcatmoit  is  the  same  as  for  septic  intoxication.  Anti- 
streptococcic serum  is  employed  b}-  some  surgeons,  but  the 
value  of  this  method  is  as  yet  doubtful. 

Pyemia. — P}-emia  is  a  condition  in  which  metastatic  ab- 
scesses arise  as  a  result  of  the  existence  of  septic  thrombo- 
phlebitis, the  disease  being  characterized  b}-  fever  of  an  in- 
termittent type  and  by  recurring  chills.  It  is  not  actually 
due  to  free  pus  in  the  blood,  but  to  the  passage  into  the 
blood  of  clots  filled  with  toxins  or  infected  by  streptococci 
and  staph}-lococci.  After  a  wound  is  inflicted  blood  clots  in 
the  divided  veins.  If  the  wound-fluid  becomes  putrid,  the  in- 
12 


1/8  SEPTICEMIA   AND  PYEMIA. 

travenous  clots  may  become  filled  with  ptoma'ins.  If  suppura- 
tion occurs,  the  clots  may  become  filled  with  the  toxins  of 
pyogenic  organisms  or  be  invaded  by  the  organisms  them- 
selves. Thus  it  becomes  evident  that  pyemia  may  develop 
with  sapremia  or  with  septicemia.  It  may  also  develop 
when  neither  has  existed.  A  suppurating  focus  about  a  vein 
may  cause  thrombophlebitis  and  clot  formation  even  when 
no  wound  exists.  This  is  seen  in  thrombophlebitis  of  the 
lateral  veins  secondary  to  suppuration  of  the  middle  ear. 

A  vessel-thrombus  runs  up  in  the  lumen  of  a  vein,  and 
the  apex  of  the  clot  softens,  a  portion  of  it  is  broken  off  by 
the  blood-stream  and  carried  as  an  embolus  into  the  circula- 
tion. Many  of  these  poisonous  emboli  enter  into  the  blood 
and  lodge  in  some  vessels  which  are  too  small  to  transmit 
them,  and  at  their  points  of  lodgement  form  embolic,  second- 
ary, or  metastatic  abscesses.  If  the  embolus  contains  only 
toxins  the  danger  is  infinitely  less  than  if  it  contains  bacteria. 
The  secondary  abscess  if  caused  by  a  clot  containing  only 
toxins  may  not  lead  to  further  dissemination  of  disease.  If 
the  embolus  contains  bacteria,  thrombophlebitis  occurs  about 
it,  and  new  infected  emboli  form  and  are  sent  throughout 
the  system.  Wounds  of  the  superficial  parts  and  bones  pro- 
duce pyemic  infarctions  and  metastatic  abscesses  of  the  lungs. 
When  these  infarctions  break  into  fragments  particles  may. 
return  to  the  heart  and  lodge,  or  may  be  sent  out  through 
the  arterial  system  to  form  other  foci  in  distant  organs.  In- 
fected areas  connected  with  the  portal  circulation  (intestinal 
injuries  or  suppurating  piles)  may  produce  abscess  of  the  Hver. 
Wounds  of  bones  which  open  the  medullary  cavity  or  diploic 
structure  are  particularly  apt  to  be  followed  by  pyemia,  and 
the  disease  may  follow  labor,  phlegmonous  erysipelas,  and 
other  conditions.  Malignant  endocarditis  is  called  "  arterial 
pyemia,"  and  is  due  to  endocardial  embolic  infection.  In  this 
disorder  infected  emboli  lodge  in  the  kidneys,  the  spleen,  the 
alimentary  tract,  the  brain,  or  the  skin  (Osier).  Idiopathic 
pyemia  is  a  misnomer.  Some  primary  focus  of  infection 
must  exist,  as  was  pointed  out  when  discussing  septicemia. 

Symptoms. — The  wound  often  becomes  dry  and  brown, 
and  sometimes  also  offensive.  A  severe  and  prolonged  chill 
or  a  succession  of  chills  ushers  in  the  disease  ;  high  fever  fol- 
lows, and  drenching  sweats  occur.  The  chills  recur  every  other 
day,  every  day,  or  oftener.  After  the  sweat  the  temperature 
falls  and  may  become  nearly  normal.  The  temperature  often 
oscillates  violently.  The  general  symptoms  of  vomiting,  wast- 
ing,  etc.,  resemble  those  of  septicemia.    -In  some  cases  the 


ERYSIPELAS.  1 79 

mind  remains  clear,  in  many  the  delirium  is  purely  nocturnal. 
The  skin  becomes  jaundiced,  and  a  profound  adynamic  state 
is  rapidly  established.  The  blood  shows  disintegration  of 
red  corpuscles  and  leukocytosis.  The  spleen  is  enlarged. 
The  lodgement  of  emboli  produces  symptoms  whose  nature 
depends  upon  the  organ  involved.  Lodgement  in  the  lungs 
causes  shortness  of  breath  and  cough,  with  slight  physical 
signs.  Lodgement  in  the  pleura  or  pericardium  gives  pro- 
nounced physical  evidence.  Lodgement  in  the  spleen  pro- 
duces severe  pain  and  great  enlargement.  The  parotid  gland 
not  unusually  suppurates. 

In  a  suspected  case  of  pyemia  always  examine  for  a  wound, 
and  if  this  does  not  exist,  remember  that  the  infection  may 
arise  from  gonorrhea,  osteomyelitis,  suppuration  in  the  middle 
ear,  appendicitis,  dental  caries,  tonsillar  suppuration,  abscess 
of  the  prostate,  etc.  Chronic  pyemia  may  last  for  months  ; 
acute  pyemia  may  prove  fatal  in  three  days.  The  chief 
complications  are  joint-suppuration,  bronchopneumonia, 
pleuritis,  endocarditis,  pericarditis,  peritonitis,  pyelitis,  venous 
thrombosis,  and  abscesses. 

Treatment  is  the  same  as  for  septicemia.  Open,  drain, 
and  asepticize  any  wound  and  any  accessible  secondary 
abscess. 

XI.  ERYSIPELAS  (ST.    ANTHONY'S   FIRE). 

Kl*ysipelas  is  an  acute,  contagious,  spreading  capillary 
lymphangitis  due  to  the  streptococci  of  er}'sipelas,  which 
grow  and  multiply  in  the  smaller  lymph-channels  of  the 
skin  and  its  subcutaneous  cellular  layers  and  also  in  the 
lymph-channels  of  serous  and  mucous  membranes.  The 
disease  is  characterized  by  a  rapidly  spreading  dermatitis,  by 
a  remittent  fever  due  to  absorption  of  toxins,  and  b}'  a  ten- 
dency to  recurrence.  It  is  always  preceded  by  a  wound,  a 
scratch,  or  an  abrasion,  which  may  have  been  tri\ial  and  may 
never  have  been  noticed.  The  so-called  idiopathic  erysipelas 
is  preceded  by  a  breach  of  surface  continuity  so  small  as  to 
escape  notice.  The  initial  point  of  infection  may  be  in  the 
mouth,  the  nostril,  the  pharjmx,  the  auditory  meatus,  between 
the  fingers  or  toes,  at  the  margin  of  a  nail,  or  in  a  cutaneous 
furrow.  The  involved  area  may  or  ma\'  not  suppurate. 
Suppuration  does  not  require  a  mixed  infection,  as  the  strep- 
tococcus is  identical  with  the  streptococcus  pyogenes.  Eiysip- 
elas  is  most  common  in  the  spring  and  fall,  and  is  most 
usually  met  with  among  those  who  are  crowded  into  dark, 


l80  ERYSIPELAS. 

dirty,  and  ill-ventilated  quarters  ;  it  attacks  by  preference 
the  debilitated  and  broken-down  (as  alcoholics  and  sufferers 
from  Bright's  disease).  The  disease  may  become  endemic 
in  special  places  or  localties.  The  poison  of  erysipelas  will 
produce  puerperal  fever  in  a  lying-in  woman.  The  strep- 
tococcus was  first  obtained  in  pure  cultures  by  Fehleisen. 
This  organism  is  widely  diffused.  The  question  of  identity 
with  the  streptococcus  pyogenes  is  discussed  on  p.  41. 

Forvis  of  Erysipelas. — Avibulant,  erratic,  migratory,  or 
wandering  erysipelas  is  a  form  which  tends  to  spread  widely 
over  the  body,  leaving  one  part  and  going  to  another. 
Bullous  erysipelas  is  attended  by  the  formation  of  bullae. 
In  diffused  erysipelas  the  borders  of  the  inflammation  grad- 
ually merge  into  healthy  skin.  Erytlieviatous  en/sipelas 
involves  the  skin  superficially.  Metastatic  er^^sipelas  appears 
in  various  parts  of  the  body.  Puerperal  erysipelas  begins 
in  the  genitals  of  lying-in  women,  producing  puerperal  fever. 
Erysipelas  simplex  is  the  ordinaiy  cutaneous  form.  Erysipelas 
neonatorum  begins  in  the  unhealed  navel  of  a  newborn  child 
and  spreads  from  this  point.  Typhoid  erysipelas  occurs  with 
profound  adynamia.  Universal  erysipelas  involves  the 
entire  body.  Cellulitis  is  er^^sipelas  of  the  subcutaneous 
layers.  Phlegmonous  eiysipelas  involves  the  skin  and  the 
cellular  tissues,  and  causes  suppuration,  and  often  gan- 
grene. Edematous  erysipelas  is  a  variety  of  phlegmonous 
erysipelas  with  enormous  subcutaneous  edema.  LympJiatic 
erysipelas  is  characterized  by  rose-red  lines  due  to  lymphan- 
gitis. Venous  erysipelas  is  marked  by  the  dark  color  of  venous 
congestion.  Mucous  erysipelas  involves  a  mucous  mem- 
brane. Eiysipelas  may  attack  the  fauces,  producing  a  very 
grave  condition. 

Clinical  Forms. — The  clinical  forms  are  cutaneous  er}^sip- 
elas,  cellulocutaneous  or  phlegmonous,  cellulitis,  and  mucous 
erysipelas. 

Cutaneous  erysipelas  most  frequently  attacks  the  face. 
A  fever  suddenly  appears,  rises  rapidly,  reaches  a  consider- 
able height,  is  remittent  in  type,  and  usually  terminates  in 
four  or  five  days  by  crisis.  At  the  time  of  febrile  onset  spots 
of  redness  appear  on  the  skin.  These  spots  run  together, 
and  a  large  extent  of  surface  is  found  to  be  red'  and  a  little 
elevated.  Any  wound,  ulcer,  or  abrasion  which  exists  becomes 
dry  and  unhealthy,  and  its  edges  redden  and  swell.  The 
erysipelatous  area  of  redness  and  swelling  extends,  its  mar- 
gin is  usually  sharply  defined  from  the  healthy  skin,  and  the 
color  fades   at  the  original  focus  as  the  disease  advances  at 


ERYSIPELAS. 


I«I 


the  periphery  of  the  red  area.     The  color  fades  at  once  on 
pressure    and    returns   at  once   when   pressure   is    removed. 
There  is  sh^ht  burning  pain,  which  is  nicreased  by  pressuie. 
In  the  hyperemic  area    vesicles   or  bullae   form,  contamu-.g 
first  serum  and  later  it  may  be  sero-pus  but  there  is  rarely 
o-enuine  suppuration  in  cutaneous  erysipelas.     Edema  attects 
die  subcutaneous  tissues,  producing  great  swelling  in  regions 
where  there  is  much  loose  cellular  tissue   (as  in  the  eyelids). 
The  anatomically  related  lymphatic  glands  may  become  large 
and    tender.       In    an  ordinarily  strong  person  the  color   is 
bri-ht  red  or  more  rarely  dark   red.     A    dusky  color  pre- 
cedes   suppuration.      A  blue   color    precedes    gangrene    or 
indicates  profound  cardiac  and  pulmonary  involvement     Eiy- 
sipelas   spreads   now  in   one  direction,  now   in  another    n 
fluenced,  according  to  Pfleger,  by  the  furrows   of  the   skin. 
When  the  disease  1:eases  to  spread  the  swelhng  and  redness 
gradually  abate,  and  after  they  disappear  desquamation  takes 
place  and  the  blebs  become  dry  and  crusted. 

In  strong  subjects  the  symptoms  of  cutaneous  erysipelas 
are  usually  slight.  In  the  old  and  debilitated  the  symp- 
toms are  typhoidal,  delirium  comes  on,  and  death  is  usual. 
Possible  complications  are  meningitis,  pneumonia,  septicemia, 
pleuritis,  pyemia,  endocarditis,  arthritis,  and  albuminuria. 
Erysipelas  neonatorum  is  generally  fatal.  In  some  instances 
an  attack  of  erysipelas  will  cure  an  old  skin  eruption,  a  new 
growth,  an  ulcer,  or  an  area  of  lupus.  This  is  the  erysipele 
salutaire  of  our  French  confreres.  _ 

Treatment.-\^o\2.t^  the  patient,  asepticize  a  wound,  if  theie 
be   a  wound,  and  administer  a  purge.     Cases  of  cutaneous 
erysipelas  occurring  in  a  fairly  healthy,  young,  or  middle- 
aged  subject,  tend  to  get  well  without  treatment^    I    a  per- 
son IS  debilitated  free  stimulation  is  necessary.     Tmcture  o 
chlorid  of  iron  and  quinin  are  usually  administered     Nutn 
tious  food  is  important.     For  sleeplessness  or  deluium  use 
chloral  or  the  bromids ;  for  high  temperature,  ^oM  sponging^ 
To  prevent  spreading  some  have  advised  injection  of  th^  heal  ny 
skin  near  the  blush  with  a  2  per  cent,  carbolic  solution  or  with 
fluid  containing  gr.  ^,  of  corrosive  sublimate.    A  band  o  lodm 
painted  on  the  skin  may  arrest  the  progress  of  the  disease, 
and  so  may^  a  ring  streaked  around  a  limb  or  about  an  ery- 
sipelatous  area  by  lunar  caustic.     Kraske   has   suggested  a 
me  hod   of   preventing   the    spread   of  cutaneous   erys^^^^^^^ 
which    is    often  effective.     The  patient    is  anesthetized.     At 
TboSt  two    inches   from  the  margin  of  the  redness  a  series 
of  cuts    are    made   into   the    skin,   to   a  sufficient  depth  to 


1 82  ERYSIPELAS. 

cause  free  oozing.  Each  cut  is  crossed  by  another  cut  and 
a  ring  of  scarifications  is  made  to  surround  the  erysipelas. 
After  the  oozing  ceases  the  scarified  area  is  soaked  for  one 
hour  with  a  solution  of  carbolic  acid  (i  :  20)  or  corrosive 
sublimate  (i  :  2000).  The  part  is  dressed  with  pads  wet  with 
carbolic  acid  (i  :  40)  or  corrosive  sublimate  (i  :  2000).  This 
operation  causes  the  formation  of  a  protective  barrier  of 
leukocytes.  Locally,  paint  the  inflamed  area  with  equal  parts 
of  iodin  and  alcohol  and  apply  lead-water  and  laudanum. 
The  iodin  is  germicidal  and  quickly  enters  the  lymph- 
spaces.  The  lead-water  and  laudanum  allays  the  burning 
pain.  If  an  extremity  be  involved,  bandage  it.  Another 
good  application  is  a  50  per  cent,  ichthyol  ointment  with 
lanolin.  A  very  useful  method  is  Von  Nussbaum's.  The 
author  applies  it  somewhat  modified,  as  follows  :  wash  the 
part  with  ethereal  soap,  irrigate  with  a  solution  of  corrosive 
sublimate  (i  :  looo),  dry  with  a  sterile  towel,  apply  an  oint- 
ment of  ichthyol  and  lanolin  (50  per  cent.),  and  dress  with 
antiseptic  gauze.  Some  use  iced-water  cloths  and  some 
prefer  hot  fomentations.  Others  apply  borated  talc  or  sali- 
cylated  starch.  Ringer  advised  painting  every  three  hours 
with  a  mixture  composed  of  gr.  xxx  of  tannic  acid,  gr.  xxx 
of  camphor,  and  siv  of  ether.  J.  M.  Da  Costa  recommends 
pilocarpin  internally  in  the  beginning  of  a  case.  Antistrepto- 
coccic serum  has  been  used  in  erysipelas,  and  great  results 
have  been  claimed  for  it.  Roger  and  Charrin's  serum  may 
be  used.  The  dose  is  30  c.c.  It  is  asserted  that  under  its 
influence  the  temperature  soon  becomes  normal.  We  have 
had  no  personal  experience  with  the  serum  treatment. 

Cellulocutaneous  or  phlegmonous  erysipelas  is  charac- 
terized by  high  temperature  (104°- 106°  F.),  the  rapid  onset  of 
grave  prostration,  irregular  chills,  sweats,  and  a  strong  ten- 
dency to  delirium.  The  constitutional  condition  may  be  one 
of  suppurative  fever,  sapremia,  septicemia,  or  pyemia.  The 
parts  are  red,  as  in  cutaneous  erysipelas,  and  the  tumefaction 
is  vastly  greater.  The  swelling  is  brawny,  comes  on  early, 
increases  with  exceeding  rapidity,  induces  a  high  degree  of 
tension,  and  frequently  produces  sloughing  or  even  cutaneous 
gangrene.  The  lymphatic  glands  are  swollen,  but  the  in- 
flamed lymphatic  vessels  are  hidden  by  the  tumefaction.  In 
most  cases  suppuration  occurs,  and  when  this  happens  the 
parts  become  boggy  and  the  pus  is  widely  disseminated  in 
the  subcutaneous  and  intramuscular  tissues,  and  even  into 
muscular  sheaths  and  tendon-sheaths  (purulent  infiltration). 
When  the  disease  abates  sloughs  form,  which  leave  ulcers 


CELLULITIS.  183 

upon  being  cast  off.  In  bad  cases  muscles,  vessels,  tendons, 
and  fascia  may  slough  away.  The  commonest  complications 
are  suppression  of  urine,  bronchopneumonia,  congestion  and 
edema  of  the  lungs,  meningitis,  congestion  of  the  kidneys, 
and  acute  pleurisy.  Septicemia  or  pyemia  may  occur.  We 
sometimes  meet  with  this  form  of  erysipelas  after  extravasa- 
tion of  urine.  It  is  not  a  pure  streptococcus  infection.  There 
is  a  mixed  infection  with  other  pyogenic  cocci,  and  often 
with  organisms  of  putrefaction. 

Treatment. — At  once  asepticize  and  drain  an\-  existing 
wound,  and  dress  such  a  wound  with  hot  antiseptic  fomenta- 
tions. If  there  are  inflamed  lymph-\essels  or  glands  above 
the  area  of  cellulocutaneous  infection,  paint  the  skin  above 
them  with  iodin  and  smear  it  with  blue  ointment.  Make 
numerous  incisions  into  the  inflamed  tissues.  These  incisions 
should  be  near  together,  and  each  cut  should  be  two  or  three 
inches  long.  Spray  the  wounds  by  means  of  hydrogen 
peroxid  in  an  atomizer,  wash  with  corrosive-sublimate  solu- 
tion (i  :  1000),  and  pack  each  wound  with  iodoform  gauze. 
Dress  with  man}-  la\'ers  of  gauze  wet  with  a  hot  solution  of 
corrosive  sublimate  and  covered  with  a  rubber-dam;  a  hot- 
water  bag  being  laid  upon  the  dressing.  If  sloughs  form, 
cut  them  partly  away  and  employ  hot  antiseptic  fomentations. 
Change  the  dressings  often.  In  some  cases  it  ma}'  be  necessary 
to  emplo}-  continuous  irrigation  with  warm  antiseptic  fluid,  or 
continuous  immersion  in  a  hot  aseptic  or  antiseptic  bath.  It 
is  not  unusually  necessary  to  operate  for  the  removal  of  en- 
larged l}-mphatic  glands.  In  rare  cases  amputation  is  de- 
manded. When  granulations  begin  to  form,  treat  as  a  healing 
wound.  The  constitutional  treatment  is  that  previously  set 
forth  as  applicable  to  septicemia,  viz.,  purgation,  the  use  of 
diuretics  and  diaphoretics,  the  administration  of  strychnin, 
quinin,  digitalis,  alcoholic  stimulants,  and  nourishing  food. 
Antistreptococcic  serum  is  employed  by  some.  In  severe 
cases  emplo}'  hypodermoch'sis  or  saline  infusion  into  a  vein. 

Cellulitis. — Cellulitis  is  a  microbic  inflammation  of  the 
cellular  tissue.  It  may  be  due  to  staphylococci,  to  strepto- 
cocci, to  other  pyogenic  bacteria,  or  to  mixed  infection  with 
two  varieties  of  pyogenic  organisms.  The  commonest  form  is 
streptococcus  infection,  and  this  is  a  variety  of  erysipelas. 
Infection  with  the  bacillus  aerogenes  capsulatus  causes  gan- 
grenous cellulitis.  In  cellulitis  of  the  subcutaneous  tissue 
the  organism  finds  entrance  by  means  of  a  wound.  Swell- 
ing precedes  redness.  The  swelling  is  not  so  marked  as 
in  phlegmonous  er}'sipelas,  and  the  redness  is  darker  and  is 


1 84  TETANUS,    OR   LOCKJAW. 

not  so  noticeable  as  in  cutaneous  erysipelas.  The  redness  of 
cellulitis  is  about  the  wound,  it  spreads  but  does  not  fade  at 
the  center  as  does  ordinary  erysipelas,  red  lines  due  to  lymph- 
angitis ascend  the  limb  from  the  infected  wound,  and  the  ana- 
tomically associated  lymphatic  glands  enlarge.  In  the 
wound  and  its  neighborhood  there  is  severe  throbbing  pain. 
The  constitutional  symptoms  of  infection  develop  rapidly.  In 
trivial  cases  the  lymphatics  dispose  of  the  poison  and  sup- 
puration does  not  occur.  In  severe  cases  pus  forms  about 
the  wound  and  lymphatic  glands  may  suppurate.  Phleg- 
monous erysipelas  may  develop,  septicemia  or  pyemia  may 
arise. 

Treatment. — Open,  disinfect,  and  drain  the  wound.  Paint 
iodin  upon  the  skin  over  inflamed  lymphatic  vessels  and 
glands  and  cover  with  ichthyol  ointment.  Dress  the  wound 
and  the  adjacent  inflamed  area  with  hot  antiseptic  fomenta- 
tions. It  may  be  necessary  to  make  incisions  as  in  phleg- 
monous erj^sipelas.  In  some  cases  it  is  necessary  to  remove 
breakine-down  glands.  The  constitutional  treatment  is  that 
used  for  septicemia. 

XII.    TETANUS,  OR    LOCKJAW. 

Tetanus  is  a  microbic  disease  invariably  preceded  by  some 
injury  and  characterized  by  spasm  of  the  voluntary  muscles. 
The  wound  may  have  been  severe,  it  may  have  been  so  slight 
as  to  have  attracted  no  attention,  or  it  may  have  been  in- 
flicted upon  the  alimentary  canal  by  a  fish-bone  or  other 
foreign  body,  or  may  have  been  situated  in  the  nose,  urethra, 
vagina,  or  ear.  The  so-called  idiopathic  tetanus  is  either  not 
tetanus  at  all,  or  the  term  expresses  the  fact  that  we  have  not 
found  the  traces  of  an  injury  which  did  exist.  Tetanus  arises 
most  frequently  after  punctured  or  lacerated  wounds  of  the 
hands  or  feet,  and  before  it  appears  a  wound  is  apt  to  sup- 
purate or  slough  ;  but  in  some  instances  the  wound  is  found 
soundly  healed.  The  fact  that  the  bacillus  of  tetanus  is 
anaerobic  explains  the  comparative  frequency  with  which 
punctured  and  lacerated  wounds  are  attacked,  for  in  such 
wounds  the  bacilli  are  deeply  lodged  in  recesses  or  cavities 
into  which  air  does  not  penetrate  or  are  covered  with  dis- 
charges which  exclude  air.  Nancrede  points  out  that  sup- 
puration favors  the  growth  of  tetanus  bacilli,  because  the 
pyogenic  organisms  consume  oxygen.  Tetanus  may  appear 
twenty-four  hours  after  an  accident,  but  it  may  not  arise 
until  several  weeks  have  elapsed.     It  prevails  more  in  certain 


SYMPTOMS.  185 

localities  than  in  others.  Colored  people  are  ven.'  suscep- 
tible, and  the  disease  may  exist  endemicalh-.  Tetanus  is  due 
to  the  growth  in  a  wound  of  a  bacillus  (first  described  by 
Nicolaier  and  first  cultivated  by  Kitasato),  the  toxic  products 
of  which,  absorbed  from  the  wound,  poison  the  ner\^ous  sys- 
tem precisely  as  would  dosing  with  stiychnin.  The  bacilli 
are  not  taken  into  the  blood,  and  only  the  toxic  products 
are  absorbed,  hence  tetanus  is  an  intoxication.  Tetanus 
bacilli  or  their  spores  are  found  particularly  in  garden-soil, 
in  the  dust  of  walls,  walks,  and  cellars,  in  street-dirt,  and 
in  the  refuse  of  stables. 

Symptoms. — Acute  tetanus  begins  within  ten  da\-s  of 
an  accident.  The  usual  period  of  incubation  is  from  three 
to  five  days.  In  most  cases  the  first  symptom  is  stiffness  of 
the  iaw  in  opening  the  mouth.  In  some  cases  the  first  symp- 
tom is  stiffness  of  the  neck,  and  the  patient  believes  he  has 
"  caught  cold."  In  an}-  case  the  neck  soon  becomes  stiff,  and 
finally  both  the  neck  and  jaw  are  as  rigid  almost  as  iron. 
The  muscles  of  deglutition  become  rigid  on  attempts  at 
swallowing.  The  muscles  of  the  back,  legs,  and  abdomen 
are  thrown  into  tonic  spasm,  but  the  arms  rareh^  suffer.  If 
the  infected  injur}"  is  on  the  hand  or  foot,  that  extremit}^ 
usually  is  found  to  be  rigid.  Spasm  of  the  face-muscles 
causes  the  ris7(s  sardouiciis,  or  sardonic  smile  (contraction 
particularl}'  of  the  vmsciilus  sardoniais  of  Santorini).  The 
contraction  of  the  muscles  of  the  back  is  often  so  powerful 
as  to  bend  the  patient  back  like  a  bow  and  allow  him 
to  rest  onh"  on  his  occiput  and  heels.  This  condition  is 
known  as  "  opisthotonos."  If  he  is  bent  forward,  so  that  the 
face  is  drawn  to  the  legs,  it  is  called  "  emprosthotonos.''  If 
his  bod}'  is  curved  sideways,  it  is  designated  "  pleurosthot- 
onos."  An  upright  position  is  "  orthotonos."  The  spasm 
ma}-  be  so  violent  as  to  cause  muscular  rupture.  The  fixa- 
tion of  the  jaw  is  called  trismus. 

The  characteristic  condition  in  tetanus  is  one  of  widely 
diffused  tonic  spasm,  aggravated  frequent!}-  b}-  clonic  spasms 
arising  from  peripheral  irritations.  These  irritations  ma}' 
be  draughts,  sounds,  lights,  shaking  of  the  bed,  attempts 
at  swallowing,  contact  of  the  bed-clothing,  the  presence  of 
urine  in  the  bladder  or  of  feces  in  the  rectum,  or  various 
visceral  actions.  The  clonic  spasms  begin  earl}-  in  the  case 
and  become  more  frequent  and  more  violent  as  the  disease 
progresses.  The  muscles  become  more  rigid  and  the  atti- 
tude produced  by  the  tonic  contraction  of  the  muscles 
is    temporaril}^    exaggerated.     The    forcible    contraction    of 


1 86  TETANUS,    OR   LOCKJAW. 

the  jaw  may  loosen  or  break  teeth.  The  spasm  of  the 
diaphragm,  of  the  glottis,  and  of  the  muscles  of  res- 
piration may  produce  death  and  always  produce  great 
dyspnea.  The  man  laboring  under  a  tetanic  convulsion 
presents  a  dreadful  picture ;  he  is  bent  into  some  unnatural 
attitude,  the  face  is  cyanotic  and  covered  with  drops  of  sweat, 
the  lips  are  covered  with  froth  which  is  often  bloody,  the  eyes 
bulge  and  are  suffused,  and  the  countenance  expresses  deadly 
terror  and  suffering.  The  agonizing  "  girdle-pain  "  so  often 
met  with  is  due  to  spasm  of  the  diaphragm.  Each  clonic 
spasm  causes  a  hideous  scream  by  the  constriction  of  the 
chest  forcing  air  through  a  contracted  glottis.  During  the 
progress  of  the  disease  constipation  is  persistent,  and  reten- 
tion of  urine  is  the  rule  (because  of  sphincter  spasm). 
The  mind  is  entirely  clear  until  near  the  end — one  of  the 
worst  elements  of  the  disease.  Swallowing  in  many  cases  is 
impossible.  Talking  is  very  difficult  and  it  is  impossible  to 
project  the  tongue.  The  muscles  throughout  the  body  feel 
very  sore.  The  temperature  may  be  normal,  but  it  is  usually 
a  little  elevated,  and  always  rises  just  before  death.  Hyper- 
pyrexia sometimes  occurs  (io8°-i  io°  F.),  and  the  temperature 
may  even  ascend  for  a  time  after  death.  Insomnia  is  obstinate. 
In  80-90  per  cent,  of  cases  of  acute  tetanus  death  occurs 
in  the  course  of  two  or  three  days.  If  a  patient  lives  a 
week,  his  chance  of  recovery  is  good.  Death  may  be  due 
to  exhaustion  or  to  carbonic-acid  narcosis  from  spasm  of 
the  glottis  or  fixation  of  the  respiratory  muscles. 

Chronic  tetanus  comes  on  late  after  a  Avound  (from  ten 
days  to  several  weeks).  The  symptoms  are  not  so  severe 
as  in  acute  tetanus.  The  muscular  spasm  is  widespread, 
but  it  may  not  be  persistent,  intervals  of  relaxation  permit- 
ting sleep  and  the  taking  of  food.  Chronic  tetanus  may  last 
some  weeks,  and  in  about  40  per  cent,  of  cases  the  dis- 
ease can  be  cured.  Trismus  neonatorum  or  trismus  nascen- 
tium,  the  lockjaw  of  the  newborn,  is  due  to  infection  of 
the  stump  of  the  umbilical  cord,  and  is  practically  invari- 
ably fatal.  Hydrophobic  tetanus,  head  tetanus,  or  cephalic 
tetanus,  is  a  condition  in  which  the  spasms  are  confined  chiefly 
to  the  face,  pharynx,  and  neck,  although  the  abdominal  mus- 
cles are  usually  also  rigid.  It  follows  head-injuries,  and  gives 
a  better  prognosis  than  does  general  tetanus. 

Diagnosis. — Tetanus  may  be  confounded  with  strychnin- 
poisoning,  with  hysteria,  or  with  tetany.  Wood's  table  makes 
the  diagnosis  clear  between  tetanus  and  hysteria :  ^ 

*  Nervous  Diseases,  by  Prof.  H.  C.  Wood. 


DIAGNOSIS. 


187 


Tetanus. 


Hysterical  Tetanus. 


Strychnin- POISONING. 


Muscular  symptoms 
usually  commence 
with  pain  and  stillness 
in  the  back  of  the 
neck,  sometimes  with 
slight  muscular  twitch- 
ing; come  ou  gradu- 
ally. Jaw  one  of  the 
earliest  parts  affected; 
rigidly  and  persistent- 
ly set. 

Persistent  muscular 
rigidity  very  generally, 
wuh  a  greater  or  less 
degree  01  permanent 
opisthotonos,  empros- 
thotonos,  pleurosthot- 
onos,  or  orthotonos. 


Consciousness  pre- 
served until  ne  ar 
death,  as  in  stryciuiin- 
poisoning. 


Draughts,  loud 
noises,  etc.,  produce 
convulsions,  as  in 
strychnin  -  poisoning  ; 
may  complain  bitterly 
of  pain. 

Eyes  open  and  rig- 
idly fixed  during  the 
convulsion. 


Commences   with 
blindness  and  weakness. 


Muscular  symptoms 
commence  with  rigidity 
of  the  neck, which  creeps 
over  the  body,  affecting 
the  extremities  last.  Jaws 
rigidh"  set  before  a  con- 
vulsion, and  remain  so 
between  the  paroxysms. 


Pei-sistent  opisthoto- 
nos and  intense  rigidity 
between  the  convulsions 
and  after  the  convulsions 
have  ceased,  the  opis- 
thotonos and  intense  rig- 
iditv  lastiuCT  for  hours. 


Consciousness  lost  as 
the  second  convulsion 
comes  on,  and  lost  with 
every  other  convulsion, 
the  disturbunce  of  con- 
sciousness and  motilitj' 
beins;  simultaneous. 


Crying-spells  alterna- 
ting with  convulsions. 


Eves  closed. 


Begins  with  exhilaration  and 
restlessness,  the  special  senses 
being  usually  much  sharpened. 
Dimness  of  vision  may  in  some 
cases  be  manifested  later,  after 
the  development  of  other  sytnp- 
toms,  but  even  then  it  is  rare. 

Muscular  symptoms  develop 
very  rapidly,  commencing  in  the 
extremities,  or  the  convulsion 
when  the  dose  is  large  seizes 
the  whole  body  simultaneously. 
Jaw  the  last  part  of  the  body 
to  be  affected ;  its  muscles  re- 
lax first,  and  even  when,  during 

j  a  severe  convulsion,  it  is  set,  it 
drops  as  soon  as  the  latter  ceases. 

1 

j      Muscular  relaxation  (rarely  a 

'  slight  rigidity)  between  the  con- 
vulsions, the  patient  being  ex- 
hausted and  sweating.  If  re- 
covery occurs,  the  convulsions 
gradually  cease,  leaving  merely 
muscular  soreness,  and  some- 
times stiflhess  like  that  felt  after 
violent  exercise. 

Consciousness  always  pre- 
served during  convulsions,  ex- 
cept when  the  latter  become  so 
intense  that  death  is  imminent 
from  suffocation,  in  which  case 
sometimes  the  patient  becomes 
insensible  from  asphyxia,  which 
comes  on  during  the  latter  part 
of  a  convulsion  and  is  almost  a 
certain  precursor  of  death. 

The  ••  slightest  breath  of  air'" 
produces  convulsion.  Patient 
niav  scream  with  pain  or  may 
express  great  apprehension,  but 
"  crving-spells  "  would  appear 
to  be  impossible. 

Eyes  stretched  wide  open. 


Partial  spasm  in   the  '       Legs    stiffly    extended    with 
leg, producing  in  Wood's    feet  everted,  as  the  spasms  affect 
cases  crossing  of  the  feet    all  the  muscles  of  the  leg. 
and  inversion  of  the  toes.  | 
If  all  the  muscles  were  ; 
involved, eversion  would 
occur,  as  the  muscles  of 
eversion  are  the  stronger.  : 


1 88  TETANUS,    OR   LOCKJAW. 

Tetany  is  distinguished  from  tetanus  by  the  milder  nature 
of  the  spasms,  by  the  greater  limitation  of  the  rigidity,  by  the 
fact  that  spasms  begin  in  the  hands  or  feet,  not  in  the  jaw  and 
neck,  and  in  most  cases  by  periods  of  distinct  intermittence. 

Treatment. — Far  better  even  than  to  treat  tetanus  well  is 
to  prevent  it.  Careful  antisepsis  will  banish  it  as  a  sequence 
of  surgical  operations  as  thoroughly  as  it  has  banished  sep- 
ticemia. Every  wound  must  be  disinfected  with  the  most 
scrupulous  care.  Every  punctured  wound  is  to  be  incised 
to  its  depth  and  thoroughly  cleaned  and  drained.  Puer- 
peral tetanus  is  prevented  by  antiseptic  midwifery,  and 
tetanus  neonatorum  is  obviated  by  the  antiseptic  treatment 
of  the  stump  of  the  cord.  When  tetanus  exists,  always  look 
for  a  wound,  and  if  one  is  found,  open  it ;  if  there  are  sloughs, 
cut  them  away,  wash  the  wound  with  peroxid  of  hydrogen 
and  then  with  a  hot  solution  of  corrosive  sublimate  (i  :  500), 
dry  the  wound  with  gauze,  paint  the  surfaces  of  the  wound 
with  bromin,  and  secure  drainage  by  packing  with  iodoform 
gauze.  Dennis  disinfects  the  wound  with  a  solution  of  tri- 
chlorid  of  iodin  (|  per  cent.). 

Keep  the  patient  in  a  darkened,  well-ventilated,  and  quiet 
apartment,  so  as  to  exclude  as  far  as  possible  peripheral  irri- 
tation. Watch  for  the  occurrence  of  retention  of  urine,  and 
use  the  catheter  if  it  is  necessary.  Secure  movements  of  the 
bowels  by  administering  salines,  castor  oil,  croton  oil,  or 
enemas.  Give  plenty  of  concentrated  liquid  food,  and  stimu- 
late freely  with  alcohol.  If  swallowing  causes  convulsions, 
give  an  inhalation  of  nitrite  of  amyl  before  an  attempt  is 
made  to  swallow.  If  this  treatment  does  not  make  swallow- 
ing possible,  partially  anesthetize  the  patient  and  feed  him  by 
means  of  a  pharyngeal  tube  passed  through  the  nose.  Large 
doses  of  the  bromid  of  potassium,  or  of  this  drug  with  chloral, 
give  the  best  results,  as  far  as  drug  treatment  is  capable  of 
giving  results.  If  bromid  is  used,  give  about  .3j  every  four  to 
six  hours.  Other  drugs  that  have  been  used  with  some  suc- 
cess are  gelsemium,  morphin,  curare,  injections  and  fomen- 
tations of  tobacco,  physostigmin,  anesthetics,  cocain,  and  can- 
nabis indica.  An  ice-bag  to  the  spine  somewhat  relieves  the 
girdle-pain.     Hot  baths  have  been  advised. 

Yandell  says,  in  summing  up  Cowling's  report  on  tetanus  •} 
"  Recoveries  from  traumatic  tetanus  have  been  usually  in 
cases  in  which  the  disease  occurs  subsequent  to  nine  days 
after  the  injury.  When  the  symptoms  last  fourteen  days, 
recovery  is  the  rule,   apparently  independent  of  treatment. 

1  A/nerican  Practitioner,  Sept.,  1870. 


TREA  TMENT.  1 89 

The  true  test  of  a  remedy  is  its  influence  on  the  histon-  of 
the  disease.  Does  it  cure  cases  in  which  the  disease  has  set 
in  previous  to  the  ninth  day  ?  Does  it  fail  in  cases  whose 
duration  exceeds  fourteen  days  ?  No  agent  tried  by  these 
tests  has  \-et  estabhshed  its  claims  as  a  true  remedy  for 
tetanus."  ' 

It  is  now  claimed  b\'  some  observers  that  we  ha\"e  a  rem- 
edy' which  fulfils  the  requirements  of  Yandell  in  the  tetanus 
antitoxin  serum  of  Tizzoni.  A  horse  is  injected  repeatedly 
with  the  toxins  obtained  from  cultures  of  tetanus  bacilli,  the 
strength  of  the  injections  being  gradually  increased.  Even- 
tually the  animal  becomes  immune  to  tetanus.  Some  days 
after  the  final  injection  a  cannula  is  placed  in  the  jugular 
vein  of  the  immunized  animal,  blood  is  drawn  into  a  sterile 
vessel  and  is  permitted  to  coagulate  during  twenty-four 
hours,  and  at  the  end  of  this  period  the  serum  is  separated 
from  the  clot,  is  evaporated  to  dr^^ness  in  a  vacuum  ov^er 
sulphuric  acid,  and  the  powder  is  placed  in  hermetically 
sealed  glass  tubes.  In  order  to  use  the  serum  dissolve  the 
powder  in  sterile  water,  in  the  proportion  of  i  gm.  to  10  c.c. 
The  fluid  serum  sold  in  the  shops  bears  this  proportion  to 
the  powder.  The  serum  can  be  given  subcutaneously  or 
intravenously  or  can  be  injected  into  the  brain.  If  used  sub- 
cutaneously, from  20  to  30  c.c.  of  the  fluid  serum  should  be 
injected  into  the  abdominal  wall,  and  this  dose  should  be 
given  every  six  or  eight  hours  until  there  is  improvement. 
Then  from  5  to  10  c.c.  should  be  given  every  six  or  eight  hours. 
As  the  symptoms  abate  the  dose  is  lessened  and  the  intervals 
between  the  doses  are  increased.  In  a  violent  case  of  tetanus 
the  first  dose  should  consist  of  40— 50  c.c,  and  this  can  be  re- 
peated in  four  or  five  hours.  In  a  case  of  tetanus  which 
recovered,  reported  by  Mixter,  enormous  doses  were  given. 
This  patient  received  in  the  aggregate  3400  c.c.  of  serum,  or 
285  c.c.  a  day.^  Roux  and  Borrel  maintain  that  the  toxins 
of  tetanus  pass  from  the  blood  into  nervous  tissue  and  are 
fixed  in  the  nerve-cells.  As  the  antitoxin  when  given  hypo- 
dermatically  or  intravenously  remains  in  the  blood,  it  can  only 
antidote  the  poison  in  the  blood  and  not  that  in  the  nerve- 
cells.  These  observers  advise  that  the  antitoxin  be  placed 
where  the  toxins  are  active,  that  is,  that  it  be  thrown  into  the 
cerebrum.  The  skull  is  trephined  or  opened  with  a  small 
drill,  a  blunt  needle  is  passed  to  the  depth  of  one  and  a  half 
inches  into  the  frontal  lobe,  and  the  serum  is  slowly  injected. 

^  Quoted  by  Hammond,  in  his  Diseases  of  the  A'ervous  System. 
*  Bostoti  Med.  and  Siirg.  Jour.,  Oct.  6,  1898. 


190  TUBERCULOSIS. 

The  serum  should  be  concentrated.  One  gram  of  dry  anti- 
toxin is  dissolved  in  5  c.c.  of  water,  and  this  amount  is  the 
proper  dose.  The  opposite  frontal  lobe  should  also  be  in- 
jected either  at  once  or  the  next  day.  Even  when  serum 
has  been  injected  into  the  cerebrum  it  should  also  be  given 
subcutaneously. 

The  value  of  the  tetanus  antitoxin  is  doubtful.  It  seems 
to  distinctly  benefit  chronic  tetanus,  but  to  have  only  a  trivial 
effect  on  the  acute  disease.  Nancrede  estimates  that  antitoxin 
treatment  has  lessened  the  mortality  of  acute  tetanus  about 
5  per  cent.  The  intracerebral  injection  is  still  an  experi- 
ment. Kitasato  has  shown  that  injections  of  iodoform  render 
animals  immune,  and  Sonnani  has  maintained  that  this  drug 
in  a  wound  prevents  the  disease.  If  antitoxin  is  not  obtain- 
able, give  hypodermatic  injections  of  iodoform,  3  to  5  grs. 
/.  i.  d. 

XIII.   TUBERCULOSIS. 

Tuberculosis  is  an  infectiv^e  disease  due  to  the  deposition 
and  multiplication  of  tubercle  bacilli  in  the  tissues  of  the 
body.  It  is  characterized  either  by  the  formation  of  tubercles 
or  by  a  widespread  infiltration,  both  of  these  conditions  tend- 
ing to  caseation,  sclerosis,  or  ulceration. 

A  tubercle  is  an  infective  granuloma,  appearing  to  the 
unaided  vision  as  a  semitransparent  gray  mass  the  size 
of    a    mustard-seed.     The    microscope    shows    that    a    gray 

tubercle  consists  of  a  number  of 
^^^g^^^^^^^^  cell-clusters,  each  cluster  constitut- 
^^^^^i^^^p  ing  a  primitive  tubercle.  A  typi- 
'Sl»^'^s'=^'^"-^'^"-'^''  cal  primitive  tubercle  shows  a  cen- 
'^'^iSt^^^^^.'^Q^f§'  ter  consisting  01  one  or  01  several 
^^'i€'fpM%^M$:MM&     polynucleated  giant-cells  surround- 


'^^&1r^^^^     ed    by    a  zone    of  epithelioid    cells 


''^^^^"^W^^iMfM^^i^  which  are  surrounded   by  an    area 

^'H^^'^^^^M^^^^^  of  leukocytes.     When  the  bacillus 

""k'^^V'-wiAf^^^  obtains  a  lodgement  the  fixed  con- 

^0^^^fym.  "ective-tissue  cells  multiply  by  kary- 

W^^^l^^.  okinesis,  forming  a  mass  of  nucleated 

•ol^f^' W®^f^i''.-'.»'*®f^*^  polygonal  or  round  cells,  called  "  epi- 

'?t^^&&iW^^  thelioid  "  from  their  resemblance  to 

'^K^^^X^  *\fe:^-^;^F  epithelial  cells,  and  at  the  same  time 

^    '"^  the  blood-supply  of  the   growth  is 

Fig.     qi. — Synovial   membrane,  i*       'j.     j    i_                 i        •              c                         j" 

showing  giant-cells  (Bowiby).  limited  by  occlusion  of  surroundmg 

vessels  through  multiplication  of  the 

cells  of  their  endotheUal  coats.     Some  of  the  epithelioid  cells 


Ti'BERCULOSlS.  I9I 

proliferate,  and  others  attempt  to,  but  fail  for  want  of  blood- 
supply.  Those  which  fail  to  multiply  succeed  only  in  dividing 
their  nuclei  and  enormously  increasing  their  bulk  (giant-cells). 
Giant-cells,  which  may  also  form  by  a  coalescence  of  epi- 
thelioid cells,  are  not  always  present.  The  presence  of  irri- 
tant bacterial  products  induces  surrounding  inflammation  and 
numbers  of  leukocytes  gather  about  the  epithelioid  cells  (Fig. 

The  bacilli,  when  found,  exist  in  and  about  the  epithe- 
lioid cells,  and  sometimes  in  the  giant-cells.  The\'  may  not  be 
found,  having  once  existed,  but  having  been  subsequently 
destroyed.  Bacilli,  when  present,  can  easily  be  overlooked. 
In  an  active  tubercular  lesion,  even  if  the  bacilh  be  not  found, 
injection  of  the  tubercular  matter  into  a  guinea-pig  will  pro- 
duce lesions  in  which  they  can  be  demonstrated.  A  tubercle 
may  caseate — a  process  that  is  destructive  and  dangerous 
to  the  organism.  Caseation  is  due  to  a  coagulation-necrosis 
arising  from  direct  microbic  action  upon  a  cellular  area  which 
contains  no  blood-vessels,  the  nutrition  of  the  area  being  cut 
off  by  obliteration  of  surrounding  vessels.  This  process 
starts  at  the  center,  and  the  entire  tubercle  becomes  converted 
into  a  soft  yellowish-gray  mass.  Caseation  forms  chees}^ 
masses,  which  may  soften  into  tubercular  pus,  may  calcif}^ 
may  become  encapsuledby  fibrous  tissue,  and  may  be  replaced 
by  an  area  of  sclerosis. 

A  tubercle  may  undergo  sclerosis,  which  is  an  attempt  on 
the  part  of  Nature  to  heal  and  repair.  Coagulation-necrosis 
occurs  in  the  center  of  the  tubercle  ;  "hyaline  transformation 
proceeds,  together  with  a  great  increase  in  the  fibroid  ele- 
ments, so  that  the  tubercle  is  converted  into  a  firm,  hard 
structure"  (Osier).  Infiltrated  tubercle  is  due  to  the  running 
together  of  many  minute  infective  foci,  or  to  widespread  infil- 
tration without  any  formation  of  foci.  Infiltrated  tubercle 
tends  strongly  to  caseate. 

The  bacillus  of  tubercle,  discovered  b}-  Koch,  is  a  little 
rod  with  a  length  equal  to  about  half  the  diameter  of  a  red 
blood-corpuscle.  It  can  be  stained  with  anilin,  and  this  stain 
is  not  removable  by  acids  (it  being  the  only  bacillus  except 
leprosy  which  acts  in  this  way).  In  its  growth  the  tubercle 
bacillus  causes  the  formation  of  toxins,  and  the  absorption 
of  toxins  induces  constitutional  symptoms.  These  bacilli 
exist  in  all  active  lesions  :  the  more  active  the  process  the 
greater  is  their  number.  They  may  be  widely  distributed, 
and  are  occasionally  though  rarely  identified  in  the  blood. 
They  exist  in   enormous   numbers   in  phthisical  sputum,  but 


192  TUBERCULOSIS. 

are  not  found  in  the  breath  of  consumptives.  Their  great 
medium  of  distribution  is  dried  sputum  mixed  with  dust. 
They  are  found  in  the  milk  of  tubercular  cows,  and  some- 
times in  the  meat  of  diseased  animals. 

Infection  may  be  due  to  hereditary  transmission.  Con- 
genital tuberculosis  is  occasionally,  though  rarely,  seen. 
Tuberculosis  is  apt  to  appear  in  young  children.  Some 
think  this  is  due  to  infection  from  without  upon  tissues 
whose  resistance  is  lowered  by  hereditary  predisposition  ; 
others  think  it  is  due  to  a  tardy  development  of  the  germs 
transmitted  by  heredity.  That  the  disease  may  be  present 
in  a  latent  form  is  shown  by  the  experiment  in  which  the 
viscera  of  the  fetus  of  a  consumptive  mother  showed  no 
tubercles,  but  produced  the  disease  in  guinea-pigs  when 
inoculated.^  Tuberculosis  may  arise  by  inoculation,  inocu- 
lation-tuberculosis being  seen  in  leather-workers  and  in  those 
who  dissect  tubercular  bodies  (butchers  and  doctors  are 
liable  to  anatomical  tubercle).  Osier  mentions  as  other  causes 
of  inoculation  the  bite  of  a  tubercular  patient,  the  washing 
of  infected  garments,  and  circumcision  in  which  suction  is 
employed  by  an  individual  with  phthisis.  Granulation-tissue, 
chronic  abscess,  and  areas  of  dermatitis  may  be  infected  from 
without  (G.  R.  Fowler).  Infection  through  the  air  is  very 
common.  The  bacteria  of  the  dried  sputum  adhere  to  par- 
ticles of  dust  and  are  carried  into  the  lungs.  Infection  by 
meat,  milk,  and  other  foods  may  arise  by  this  dust  settling 
upon  them  in  quantity,  but  more  often  it  is  due  to  disease 
of  the  animals.  Milk  is  a  common  vehicle  of  contagion, 
and  it  can  be  infected  even  when  an  ulcerated  udder  does 
not  exist. 

InfectioJi  is  favored  by  hereditary  predisposition — that  is 
to  say,  by  hereditary  tissue-weakness,  which,  by  maintaining 
a  lowered  momentum  of  nutritive  processes,  lessens  the  nor- 
mal resistance  to  infection.  Hutley  studied  432  cases  of 
tuberculosis.  In  23.8  per  cent,  one  or  both  parents  had  the 
disease  (the  father  alone  in  1 1.5  per  cent.,  the  mother  alone 
in  9.9  per  cent.,  and  both  in  2.4  per  cent.).  Two  types  of 
these  predisposed  persons  are  mentioned:  (i)the  sanguine 
type,  or  those  with  oval  faces,  clear  skin,  large  blue  eyes, 
long  lashes,  a  nervous  manner,  precocious  minds,  little 
fat,  and  with  long,  slender  bones,  these  children  being  often 
graceful  and  beautiful ;  and  (2)  those  with  stolid  counte- 
nances, thick  lips  and  noses,  thick,  muddy  skin,  dark,  coarse 
hair,  swollen  necks,  heavy  bones,  clumsy  gait,  and  ungainly 

'  Quoted  by  Osier  from  Birch-Hirschfeld. 


SCROFULA.  193 

figure.  The  latter  type  is  the  phlegmatic  form — the  classical 
scrofula. 

Tubercle  tends  to  arise  at  points  where  the  normal  resist- 
ance of  the  tissue  is  lessened  by  disease  or  injury,  the  process 
of  phagocytosis  being  in  such  a  spot  limited  in  activity,  and 
the  germicidal  power  of  the  body-fluids  being  at  a  low  ebb. 
The  organisms,  which  are  destroyed  by  healthy  cell-activities, 
are  victorious  when  those  activities  are  diminished.  Catar- 
rhal inflammations  of  the  air-passages  favor  phthisis,  and 
slight  traumatism  is  not  unusually  followed  by  a  develop- 
ment of  tubercle.  Severe  traumatism  is  rarely  followed  by 
tubercular  trouble.  It  is  probable  that  in  a  slight  trauma- 
tism a  sufficient  number  of  leukocytes  do  not  gather,  and  a 
sufficient  amount  of  serum  is  not  effused  to  kill  the  bacteria. 
Lowered  health,  impure  air,  and  improper  or  insufficient  food 
all  favor  the  development  of  tubercle.  When  an  area 
becomes  tubercular  it  is  not  unusual  for  indican  to  appear  in 
the  urine.  Any  tubercular  process  tends  to  spread  locally 
and  to  produce  inflammation.  A  tubercular  area  is  always 
a  danger  to  the  system  ;  from  this  as  a  focus  dissemination 
may  occur,  tubercular  lesions  appearing  in  a  distant  part  or 
general  tuberculosis  setting  in. 

Scrofula  is  not  a  disease.  It  is  a  condition  of  tissues  in 
which  low  resisting  power  makes  them  hospitable  hosts  to  in- 
vading bacilli  of  tubercle.  Some  obser\'ers  teach  that  scrofula 
is  tuberculosis  of  bones,  glands,  and  joints;  others  teach  that 
it  is  latent  tuberculosis  until  some  cause  lights  it  into  activity ; 
while  still  others  say  that  it  is  a  tendency  rather  than  a  dis- 
ease. It  is  certain  that  some  lesions  of  scrofula  are  not  tu- 
bercular (eczema  capitis,  facial  eczema,  corneal  ulcers,  gran- 
ular lids,  and  chronic  catarrhal  inflammations),  and  that  they 
result  from  ill-health,  poor  nutrition,  bad  air,  and  improper 
diet.  A  person  who  is  recognized  as  of  a  scrofulous  type 
may  never  develop  tubercular  lesions.  It  is  unquestionable, 
however,  that  strumous  subjects  are  peculiarly  apt  to  develop 
true  tubercular  lesions.  These  lesions  often  appear  after  a 
tissue  or  an  organ  has  become  the  seat  of  a  primary  non- 
tubercular  inflammation  ;  the  bacilli,  which  could  not  live  in 
the  healthy  tissue,  thrive  in  the  tissue  weakened  by  disease. 
Scrofula  is  generally  of  congenital  origin,  one  or  both  parents 
being  tubercular,  scrofulous,  or  in  ill-health  ;  it  may,  how- 
ever, be  acquired  as  a  result  of  poor  food,  bad  air,  crowding, 
and  general  lack  of  sanitation.  The  scrofulous  are  ver}^ 
prone  to  develop  tubercular  lesions  of  bones,  joints,  and 
lymphatic  glands. 

13 


1 94  TUBERCUL  OSIS. 

Tubercular  Abscess. — For  description  of  Tubercular 
Abscess,  see  p.  1 34. 

Tuberculosis  of  the  S^sSxi.—Liipiis  begins  before  the 
age  of  twenty-five,  most  usually  upon  the  face,  especially 
the  nose.  Three  forms  are  recognized  :  (i)  lupiis  vulgaris, 
in  which  pink  nodules  appear  that  after  a  time  ulcerate  and 
then  cicatrize  partly  or  completely.  These  nodules  resemble 
jelly  in  appearance ;  (2)  hipus  exedens,  in  which  ulceration  is 
very  great ;  and  (3)  lupus  hypertrophicus,  in  which  large 
nodules  or  tubercles  arise.  Lupus  may  appear  as  a  pimple, 
as  a  group  of  pimples,  or  as  nodules  of  a  larger  size.  The 
ulcer  arises  from  desquamation,  and  is  surrounded  by  inflam- 
matory products  which,  by  progressively  breaking  dow^n,  add 
to  the  size  of  the  raw  surface.  The  ulcer  is  usually  super- 
ficial, is  irregular  in  outline,  the  edges  are  soft  and  neither 
sharp  nor  undermined,  the  sofe  gives  origin  to  a  small  amount 
of  thin  discharge,  the  parts  about  are  of  a  yellow-red  color, 
the  edges  are  solid  and  puckered  and  scar-like,  and  there  is 
no  pain.  The  ulcer  is  often  crusted,  the  crusts  being  thin  and 
of  a  brown  or  black  color ;  it  may  be  progressing  at  one 
point  and  healing  at  another ;  it  is  slow  in  advancing,  but 
often  proves  hideously  destructive.  The  scars  left  by  its 
healing  are  firm  and  corrugated,  but  are  apt  to  break  down. 
Clinically  it  is  separated  from  a  rodent  ulcer  by  several  points. 
The  rodent  ulcer  is  deep,  its  edges  are  everted,  and  the  parts 
about  filled  with  visible  vessels.  It  is  not  crusted,  has  not  a 
puckered  edge,  does  not  spontaneously  heal  at  any  point, 
and  its  edges  and  base  are  hard. 

Anatomical  tubercle,  the  verruca  necrogenica  of  Wilks, 
is  due  to  local  inoculation  with  tubercular  matter.  It  is  met 
with  in  surgeons,  the  makers  of  post-mortems,  leather- 
workers,  and  butchers,  usually  upon  the  backs  of  the  hands 
and  fingers.  It  consists  of  a  red  mass  of  granulation-tissue 
having  the  appearance  of  a  group  of  inflamed  warts.  Pus- 
tules often  form. 

Scrofulodermata  or  tubercular  guminata  are  chronic 
inflammations  of  the  skin,  the  granulation-tissue  product  of 
which  caseates,  mixed  infection  occurs,  and  small  abscesses, 
sinuses,  or  ulcers  form.  A  tubercular  ulcer  has  a  floor  of  a 
pale  color,  and  has  no  granulations  at  all,  or  is  covered  with 
large,  pale,  edematous  granulations.  The  discharge  is  thin 
and  scanty.  It  is  surrounded  by  a  considerable  zone  of 
purple,  tender,  and  undermined  skin,  which  is  apt  to  slough. 
When  healing  occurs  the  skin  puckers  and  usually  inverts. 

Tuberculosis  of  Subcutaneous  Connective  Tissue. 


PERITOXEAL    TUBERCULOSIS.  I95 

— In  this  form  of  tuberculosis  nodules  of  granulation-tissue 
form  and  break  down  (^tubercular  abscesses).  In  the  deeper 
tissues  these  abscesses  are  usually  associated  with  bone-, 
joint-,  or  lymphatic-gland  disease  (see  Cold  Abscess,  p.  134). 

Tuberculosis  of  the  Mammary  Gland. — (See  p.  137). 

Pulmonary  Tuberculosis. — In  adults  the  lungs  are 
more  commonly  affected  than  any  other  structure.  The 
lung  affection  may  be  primary  or  may  be  secondary  to  some 
distant  tubercular  process.  Pulmonaiy  tuberculosis  belongs 
to  the  province  of  the  physician  and  requires  no  description 
here. 

Tuberculosis  of  the  Alimentary  Canal. — A  tuber- 
cular ulcer  of  the  Up  occasionally  occurs,  and  may  be  mis- 
taken for  a  cancer  or  a  chancre.  A  tubercular  ulcer  of  the 
tongue  is  commonly  associated  with  other  foci  of  disease. 
Such  ulcers  are  separated  from  cancer  by  their  soft  bases 
and  edges  and  by  the  rarity  of  glandular  enlargements, 
and  from  syphilitic  processes  by  the  therapeutic  test.  Con- 
firmation of  the  diagnosis  is  obtained  by  cultivations  and  in- 
oculations. Tubercle  may  affect  the  pharynx,  palate,  tonsils, 
and  ver\'  rarely  the  stomach.  It  is  thought  that  the  acid 
gastric  juice  must  protect  the  stomach  from  tubercle,  because 
tubercle  bacilli  are  frequently  introduced  into  the  stomach, 
but  the  organisms  \&xy  rarely  lodge  and  multiply  in  the 
stomach-wall. 

Intestinal  tuberculosis  may  follow  pulmonary  tuber- 
culosis, but  it  may  arise  primarily  in  the  mucous  membrane 
of  the  bowel  or  result  from  tubercular  peritonitis.  Intestinal 
tuberculosis  causes  diarrhea  and  fever,  may  resemble  appen- 
dicitis, and  may  cause  abscess  and  perforation.  Fistula  in 
ano  is  frequently  tubercular,  and  when  it  is  the  lungs  are  very 
often  involved,  the  pulmonary  lesion  being  usually  primary. 

Tuberculosis  of  the  I^iver. — Tubercular  disease  of  the 
liver  causes  cold  abscess  or  cirrhosis. 

Peritoneal  tuberculosis  maybe  priman,-,  infection  hav- 
ing been  by  way  of  the  blood,  may  be  part  of  a  diffused 
process,  or  may  follow  intestinal  tubercle,  the  serous  and 
muscular  coats  of  the  bowel  having  been  at  some  point  in 
contact  or  a  follicular  ulcer  having  perforated  (Abbe).  The 
germ  may  have  entered  by  the  Fallopian  tube.  It  may  be 
due  to  ovarian  or  Fallopian  tuberculosis,  or  to  ulceration 
of  a  tubercular  appendix.  It  usually  causes  ascites,  tym- 
pany, and  tumor-like  formations  composed  of  adherent 
bunches  of  bowel  or  omentum  or  distended  mesenteric 
cflands. 


1 96  TUBERCUL  OS  IS. 

The  pericardium  may  be  attacked  with  primary  tuberculo- 
sis, or  the  process  may  be  secondary  to  pleural  tuberculosis. 

Tuberculosis  of  the  pleura  is  not  uncommon.  Tuber- 
cular pleurisy  may  be  acute  or  chronic.  In  some  instances 
mixed  infection  takes  place  and  suppuration  occurs.  The 
tuberculosis  may  be  primary,  but  is  usually  secondary  to 
pulmonary  tuberculosis,  and  may  be  due  to  direct  extension 
or  to  the  rupture  of  an  area  of  pulmonary  softening. 

Tuberculosis  of  the  brain  induces  meningitis  and 
hydrocephalus   (p.  674). 

Tubercular  disease  of  bone  is  very  common  in  youth, 
and  is  usually  preceded  by  a  sprain  or  a  contusion,  which  is 
oftener  slight  than  severe.  The  injury  establishes  a  point  of 
least  resistance,  and  in  the  damaged  area  the  bacilli  are 
deposited  and  multiply.  The  organisms  may  be  deposited 
directly  from  the  blood,  or  may  arrive  in  an  embolism  from 
a  distant  tubercular  focus  (lung  or  lymph-gland),  which 
embolus  is  caught  in  a  terminal  artery  in  the  end  of  a  long 
bone  and  causes  a  wedge-shaped  infarction  (Warren). 

Tubercular  osteitis,  as  a  rule,  begins  just  beneath  the 
articular  cartilage  or  in  the  epiphysis  (Warren).  The  prod- 
ucts of  the  tubercular  inflammation  may  be  absorbed,  may 
be  encapsuled  by  fibrous  tissue,  or  may  caseate. 

Tubercular  disease  of  the  joints  is  called  "white 
swelling  "  and  also  pulpy  degeneration  of  the  synovial  mem- 
brane. Joints  are  especially  liable  to  tuberculosis  in  youth, 
although  the  wrist  and  shoulder  not  infrequently  suffer  in 
adult  life.  Joint-tuberculosis  is  often  preceded  by  an  injury. 
The  tubercular  process  may  begin  in  the  synovial  membrane. 
Primary  synovial  tuberculosis  is  most  often  met  with  in  the 
knee-joint.  Usually  the  disease  begins  in  the  head  of  a 
bone,  dry  caries  resulting,  necrosis  ensuing,  or  an  abscess 
forming  which  may  break  into  the  joint. 

TuberculgsiS-jaLiym^jliatic  glands  is  known  as  "ju-^ 
bercular  adenitis."  It  is  the  most  typical  reslort  of  scrofula. 
The  common  antecedent  of  a  tubercular  adenitis  of  the  neck 
is  slight  glandular  enlargement  as  a  result  of  catarrhal  in- 
flammation of  the  mucous  membrane  of  the  mouth.  Tuber- 
cular adenitis  is  most  frequent  between  the  third  and  fifteenth 
years.  A  person  not  of  the  tubercular  type  may  acquire 
tuberculosis  of  the  glands,  but  the  disease  is  unquestionably 
of  much  greater  frequency  in  those  who  are  recognized  as 
predisposed  to  tuberculosis.  Tubercular  glands  may  get 
well,  may  even  calcify,  but  usually  caseate  if  left  alone. 
After    healing  they  may  break    down    and  soften  (residual 


TUBERCULOSIS   OF   THE    TESTICLE.  1 97 

abscess).  They  very  frequently  suppurate  because  of  mixed 
infection.  Though  at  first  a  local  disease,  tubercular  glands 
may  prove  to  be  a  dangerous  focus  of  infection,  furnishing 
bacteria  which  are  carried  by  blood  or  lymph  to  distant 
organs  or  throughout  the  entire  system.  Glandular  enlarge- 
ment is  in  rare  instances  widely  diffused,  but  it  is  far  more 
commonly  localized.  Enlargement  of  the  cervical  glands  is 
most  common.  Tubercular  disease  of  the  mesenteric  glands 
causes  tabes  mesenterica. 

Cervical  lymphadenitis  may  be  confused  with  lymphade- 
jioma.  _  The  former,  as  a  rule,  first  appears  in  the  submaxil- 
lary triangle,  the  latter  in  the  occipital  or  sternomastoid 
glands.  Tubercular  glands  weld  together,  they  are  apt  to 
remain  locaUzed  for  a  considerable  time,  and  they  tend  to 
soften.  They  may  be  accompanied  by  other  tubercular 
manifestations.  Lymphadenoma  from  the  start  affects  many 
glands,  it  may  be  in  several  regions,  although  in  some  cases 
there  is  a  distinct  beginning  in  one  region.  Lymphadenoma 
shows  very  little  tendency  to  suppurate  and  does  not  break 
down  except  late  in  the  course  of  the  disease,  and  is  accom- 
panied by  great  debility  and  anemia.  Malignant  gland- 
tumors  infiltrate  adjacent  glands  and  other  structures,  binding 
skinT muscles,  and  glands  into  one  hard,  firm  mass. 

Tuberculosis  of  the  Kidney  (page  958). — Tubercu- 
losis may  affect  the  ureter,  bladder,  prostate  gland,  seminal 
vesicles,  urethra,  Fallopian  tube,  ovary,  and  uterus. 

Tuberculosis  of  the  Testicle. — This  disease  is  not 
rare.  It  is  rarely  primary,  being  usually  preceded  by  tuber- 
culosis of  the  kidney,  bladder,  or  prostate.  But  one  testicle 
is  affected  in  the  beginning,  but  the  other  gland  is  apt  to  be 
attacked  later.  The  disease  appears  as  a  painless  nodule  in 
the  epididymis,-  and  as  the  testicle  and  the  vaginal  tunic 
become  involved  a  hydrocele  forms.  The  tubercular  mass 
softens,  becomes  adherent  to  the  scrotum  and  breaks  or 
bursts,  exposing  the  damaged  testicle  (fungus  of  the  testicle). 
The  cord  is  always  involved  in  tuberculosis  of  the  testicle. 

Diagnosis  of  Surgical  Tuberculosis. — The  diagnosis 
may  be  determined  by  purely  clinical  facts.  It  may  require 
the  use  of  the  microscope,  cultivation-experiments,  or  inocu- 
lations. In  a  suspected  tubercular  lesion  remove  a  portion 
of  the  tissue  if  it  be  accessible  (by  Mixter's  cannula),  and 
make  sections,  stains,  and  cultivations.  If  no  bacilli  are 
found,  inoculate  a  guinea-pig  with  the  suspected  material. 
If  it  be  tubercular,  the  animal  will  develop  miliary  tuber- 
culosis in  a  few  weeks. 


198  TUBERCULOSIS. 

Prognosis, — The  prognosis  varies  with  the  age,  sex,  dura- 
tion, extent,  and  situation  of  the  lesion.  The  prognosis  is 
best  in  children,  and  is  better  in  males  than  in  females. 
Tuberculosis  of  the  skin  gives  a  fair  prognosis.  Tubercular 
adenitis  is  often  cured.  Any  tubercular  lesion  is,  however,  a 
menace  to  the  organism,  and  tends  strongly  to  recurrence. 

Treatment. — Destroy  the  bacilli  present  and  radically  re- 
move infected  areas  which  are  accessible.  Never  be  satisfied 
with  the  removal  of  part  of  a  diseased  focus.  Incomplete 
operations  are  apt  to  be  followed  by  diffuse  tuberculosis, 
because  many  pathways,  vascular  and  lymphatic,  are  opened 
to  infection.  Among  the  many  drugs  which  have  been 
recommended  for  local  use  we  mention  the  following :  iodin, 
carbolic  acid,  guaiacol,  arsenous  acid,  corrosive  sublimate, 
chlorid  of  zinc  (Lannolongue),  phosphate  of  iron,  balsam 
of  Peru  (Landerer),  camphorated  naphtol,  oil  of  cinnamon, 
cinnamic  acid  (Landerer),  and  iodoform.^  Iodoform  used 
locally  upon  or  in  tubercular  areas  is  of  great  value,  and 
there  is  no  drug  which  takes  its  place.  Lupus  may  be 
treated  by  the  application  of  blue  ointment ;  by  curetting, 
cauterizing  with  carbolic  acid,  and  dressing  with  iodoform  ; 
by  excision,  followed  in  some  instances  by  sliding  in  of  a 
flap  of  sound  tissue  or  immediate  skin-grafting.  If  treating 
a  nodular  and  non-ulcerated  area,  wash  it  with  a  2  per  cent, 
solution  of  corrosive  sublimate  and  inject  several  nodules 
with  camphorated  naphtol,  one  drop  for  each  nodule.  In 
seven  or  eight  days  inject  other  nodules,  and  so  on.  Koch's 
lymph  has  cured  some  cases  of  lupus.  Enlarged  glands 
of  uncertain  character  and  very  recent  tubercular  enlarge- 
ments should  be  treated  by  rubbing  ichthyol  into  the  skin 
over  the  glands  and  treating  the  patient  hygienically,  and  by 
the  internal  administration  of  antitubercular  drugs.  If  this 
plan  fails  to  cure,  the  glands  should  be  removed.  When 
glands  break  down  they  should  be  removed,  or  should  be 
opened,  curetted,  and  packed.  The  rule  must  be  to  com- 
pletely dissect  out  enlarged  lymphatic  glands  which  fail  to 
quickly  respond  to  treatment,  removing  capsules  and  glands. 
In  any  tubercular  trouble  climate  is  of  very  great  impor- 
tance. Osier  sums  up  climatic  necessities  as  "  pure  at- 
mosphere, equable  temperature,  and  maximum  amount 
of  sunshine."  Open-air  life  is  imperative.  The  patient 
must  have  a  well-ventilated  sleeping-room,  and  his  house 
should  be  free  from  dampness.     Nourishing  diet  is  essen- 

1  See  article  upon  "  Tuberculosis,"  by  George  Ryerson  Fowler,  Brooklyn 
Med.  Jour.,  Nos.  8  and  9,   1894. 


TUBERCULOSIS   OF  THE    TESTICLE.  1 99 

tial.  To  secure  a  gain  in  weight  is  a  constant  aim.  Give 
meat,  milk,  cream,  butter,  and  cod-liver  oil.  The  oil  is 
poorly  borne  in  hot  weather,  during  which  period  it  should 
be  discontinued.  Advancing  doses  of  beechwood,  creasote, 
guaiacol  carbonate,  arsenic,  quinin,  and  stimulants  have  their 
uses.  (For  treatment  of  tuberculosis  of  bones,  joints,  peri- 
toneum, pleura,  etc.,  look  under  special  regional  headings.) 

Bier's  Method. — A  few  years  ago  Bier  set  forth  a  new 
plan  for  treating  tubercular  lesions.  It  consists  in  causing 
venous  obstruction  and  passive  congestion.  In  the  area  of 
passive  congestion  the  tissue-cells  form  antitoxins  which 
kill  the  bacteria  or  attenuate  their  virulence.  The  treatment 
is  founded  upon  the  principle  announced  by  Laennec,  that 
"  cyanosis  is  antagonistic  to  tubercle."  The  plan  is  applied 
particularly  in  joint-tuberculosis.  An  elastic  band  three 
inches  broad  is  placed  around  the  limb,  above  the  seat  of 
disease,  and  it  is  applied  sufficiently  tight  to  cause  conges- 
tion. Several  pieces  of  lint  ought  to  be  interposed  between 
the  skin  and  the  band.  By  applying  a  flannel  bandage 
from  the  peripher}-  to  the  lower  border  of  the  disease  the 
congestion  is  limited  to  the  area  of  trouble.  The  patient 
should  wear  the  band  continually  and  move  about  with  it 
on.  Some  people  wear  it  without  any  inconvenience,  but 
others  complain  greatly  after  wearing  it  but  a  short  time. 
Bier  and  others  have  reported  cures. 

Koelis  Tuberctilin. — The  specific  treatment  by  Koch's  tu- 
berculin or  paratoloid  has  excited  widespread  interest.  It 
has  not  fulfilled  the  expectations  which  many  entertained, 
but  does  benefit  some  cases,  notably  lupus.  A  serious  draw- 
back to  the  value  of  Koch's  tuberculin  is  that  it  often  causes 
fever  and  inflammation  to  a  dangerous  degree.  In  some 
cases,  as  Virchow  showed,  it  produces  acute  miliar^'  tubercu- 
losis. Koch's  lymph  is  a  glycerin -extract  of  a  culture  of 
tubercle  bacilli,  and  the  usual  dose  is  i  milligram,  given  hy- 
podermaticalh^  into  the  back  by  Koch's  pistonless  syringe. 
After  it  has  been  used  for  a  time  the  dose  may  be  increased 
to  10  milligrams,  or  even  much  more.  Bergmann  gave  i 
gram.  Koch's  lymph  causes  inflammation  and  necrosis  of 
tubercular  tissue  b}-  the  action  of  certain  antitoxins.  jNIany 
cases  it  improves.  Some  cases  it  apparenth*  cures,  but  the 
disease  is  apt  to  return.  In  pulmonar}-  tubercle  it  must  not 
be  given  if  there  be  much  fever  or  extensive  consolidation. 
Chiene  used  tuberculin  largely  in  joint-cases  by  gi\"ing  two 
or  three  doses  a  day  and  increasing  the  dose.  It  is  best  to 
associate  other  treatment  with  the  l}'mph.     Tuberculin  may 


200  RHACHITIS,    OR   RICKETS. 

be  used  for  diagnostic  purposes  in  animals.  If  tuberculosis 
exists,  an  injection  of  tuberculin  produces  a  marked  reaction. 
Czerny  has  shown  that  in  renal  tuberculosis  in  a  human 
being  bacilli  are  often  absent  from  the  urine,  but  an  injection  of 
tuberculin  will  cause  bacilli  to  appear  plentifully.  Koch  has 
recently  modified  his  tuberculin.  He  makes  it  as  follows : 
dried  cultures  of  bacilli  are  mixed  with  distilled  water,  and 
the  mixture  is  agitated  in  a  centrifuge.  Two  layers  separate. 
The  upper  layer  is  the  old  tuberculin.  The  lower  layer  is 
the  new  tuberculin.  The  new  tubercuHn  is  given  hypoder- 
matically,  at  first  in  very  small  doses,  but  finally  in  doses  as 
large  as  20  milligrams.  It  is  not  to  be  given  in  far  advanced 
cases  or  cases  with  much  fever. 

Hunter,  of  London,  declares  that  Koch's  old  lymph  contains 
one  principle  which  causes  fever,  another  which  causes  in- 
flammation, and  a  third  which  produces  atrophy  of  tuber- 
cular foci  without  either  fever  or  inflammation.  This  third 
desirable  element  he  believes  he  has  isolated  in  what  is 
called  a  "  derivative  of  tuberculin,"  a  modified  lymph.  Some 
remarkable  results  have  followed  the  use  of  this  material ; 
its  administration  seems  entirely  safe,  and  it  should  thor- 
oughly and  carefully  be  tried  to  ascertain  its  true  rank  as  a 
remedy.  The  injection  of  serum  obtained  from  animals  re- 
fractory to  tubercle  has  been  employed,  but  Richet  and 
Hericourt  have  seen  no  benefit  from  the  plan.  Maragliano, 
of  Genoa,  uses  a  serum  which  he  believes  can  cure  tubercu- 
losis. He  immunizes  animals  not  by  injection  of  living  cult- 
ures, but  by  employing  the  toxic  principles  extracted  from 
them.  Progressive  vaccinations  immunize  a  dog.  The  serum 
of  the  animal  is  injected  for  the  cure  of  tuberculosis  in  man 
or  other  animals.  If  injected  along  with  tuberculin,  it  neu- 
tralizes the  general  and  local  reaction  of  the  latter  agent.  The 
serum  has  apparently  benefited  some  cases,  but  is  certainly 
useless  against  mixed  infections.^ 

XIV.  RHACHITIS,  OR   RICKETS. 

Rickets  is  a  constitutional  disease  arising  during  the 
early  years  of  life  (the  first  two  or  three)  as  a  result  of 
insufficient  or  of  improper  diet  and  bad  hygienic  surround- 
ings. A  deficiency  of  fat  and  phosphate  in  the  food  or  the 
use  of  a  diet  which,  by  inducing  gastro-intestinal  catarrh, 
prevents  assimilation,  causes  rickets.  The  disease  is  never 
congenital,  the  so-called  "  congenital  rickets  "  being  sporadic 
cretinism  (Bowlby). 

1  Brit.  Med.  Jour.,  1895,  "•  444- 


SCURVY.  20 1 

Evidences  of  Rickets. — The  condition  is  one  of  gen- 
eral ill-health;  the  child  is  ill-nourished,  pallid,  flabby;  it 
has  a  tumid  belly  and  suffers  from  attacks  of  diarrhea  and 
sick  stomach ;  it  is  disinclined  for  exertion  and  has  a  capri- 
cious appetite ;  it  is  liable  to  night-sweats  and  night-terrors  ; 
enlarged  glands  are  often  noted,  the  teeth  appear  behind 
time,  and  the  fontanels  close  late.  The  long  bones  become 
much  curved,  the  upper  part  of  the  chest  sinks  in,  curvature 
of  the  spine  appears,  the  head  is  large  and  the  forehead 
bulges,  and  the  pelvis  is  distorted.  SA\-elling  appears  in  the 
articular  heads  of  long  bones,  by  the  side  of  the  epiphyseal 
cartilages,  and  in  the  sternal  ends  of  the  ribs,  forming  in  the 
latter  case  rhachitic  beads.  The  lesions  of  rickets  are  due  to 
imperfect  ossification  of  the  animal  matter  which  is  prepared 
for  bone-formation,  and  the  soft  bones  gradually  bend.  The 
swellings  at  the  articular  heads  are  due  to  pressure  forcing 
out  the  soft  bone  into  rings.  Rhachitic  children  rarely  grow 
to  full  size,  and  the  disease  is  responsible  for  many  dwarfs. 
Most  cases  recover  without  distinct  deformity,  but  the  time 
lost  during  the  period  when  active  development  should  have 
gone  on  cannot  be  made  up,  and  some  slight  deficiency  is 
sure  to  remain.  Bowlegs,  knock-knees,  and  spinal  curvatures 
are  usually  rhachitic  in  origin.  The  disease  may  be  associated 
with  scurvy,  inherited  syphilis,  or  tuberculosis. 

Treatment. — The  treatment  consists  in  having  the  child  li\-e 
as  much  as  possible  in  the  open  air  and  sunshine.  Salt- 
water baths  are  useful.  Sea-air  is  very  beneficial.  Fresh 
food  (milk,  cream,  and  meat-juice)  should  be  ordered.  Cod- 
liver  oil,  syrup  of  the  iodid  of  iron,  arsenic,  and  some  form 
of  phosphorus  are  to  be  administered.  It  is  absolutely  neces- 
sar}^  to  improve  the  primary  assimilation. 

Scurvy. — This  disease  is  rare  to-day  in  adults,  but  was 
at  one  time  very  common  among  those  who  took  long 
voyages,  or  who  engaged  in  campaigns,  or  were  the  \-ictims 
of  sieges.  Of  recent  years  it  is  \-eiy  uncommon,  and  has 
occurred  chiefly  among  voyagers  in  the  Arctic  regions. 

It  is  a  constitutional  malady  due  to  the  consumption  of 
improper  diet,  and  especially  to  the  emplo}'ment  of  a  diet 
characterized  by  the  absence  of  vegetables. 

The  use  of  salt  meat  as  a  staple  article  seems  to  favor  the 
production  of  the  disease.  Garrod  considered  absence  of 
potassium  salts  to  be  the  real  cause.  Absence  of  variet)-  in 
diet,  bad  water,  poorly  ventilated  quarters,  and  insufficient 
exercise  favor  the  development  of  the  disease. 

The    disease  begins  with  weakness,  drowsiness,  muscular 


202  RHACHITIS,    OR   RICKETS. 

pains,  and  great  susceptibility  to  cold.  The  skin  is  pallid 
or  dirty  white,  and  is  occasionally  mottled  and  often  peels 
off.  The  pulse  is  excessively  weak  and  slow.  There  is  no 
fever.  After  two  or  three  weeks  the  gums  become  tender, 
painful,  and  swollen,  and  bleed  at  frequent  intervals ;  the 
breath  becomes  offensive,  the  teeth  loosen  and  even  drop 
out ;  subcutaneous  hemorrhages  take  place,  giving  rise  to 
petechiae  or  extensive  extravasations ;  the  vision  becomes 
dim  ;  the  urine  becomes  scanty  and  of  low  specific  gravity ; 
vesicles  form,  rupture,  and  give  rise  to  bleeding  ulcers,  and 
ulcers  likewise  arise  from  breaking  down  of  blood  extravasa- 
tions ;  ^  hemorrhages  take  place  into  and  between  the  mus- 
cles, and  in  severe  cases  beneath  the  periosteum  and  into 
joints,  and  blood  may  flow  from  the  nose,  lungs,  kidneys,  stom- 
ach, and  intestines.  Deep  hemorrhages  are  felt  as  hard  lumps. 
Bleeding  at  an  epiphyseal  line  may  separate  the  epiphysis 
from  the  shaft.  If  an  inflammation  or  ulceration  arises  at 
any  point,  fever  is  observed.  It  was  observed  by  DeHaven 
in  the  Grinell  expedition  in  search  of  Sir  John  Franklin  that 
scurvy  causes  old  and  soundly  healed  wounds  to  ulcerate. 
Most  cases  get  well  under  proper  treatment,  but  complete 
recoveiy  is  not  attained  for  a  long  time.  It  is  important  to 
remember  that  though  scurvy  is  rare  in  adults,  it  is  by  no 
means  uncomimon  in  ill-nourished  infants.  The  author  has 
seen  two  cases,  in  one  of  which  a  large  subperiosteal  hemor- 
rhage was  mistaken  for  sarcoma  of  the  femur.  Infantile 
scurvy  may  exist  with  rickets. 

Treatment. — Give  vinegar,  lemon-juice,  onions,  scraped 
apples,  cider,  nitrate  of  potassium,  antiseptic  mouth-washes, 
strychnin,  plenty  of  nourishing  food,  and  whiskey  or  brandy. 
Secure  sleep  and  treat  the  ulcers  by  antiseptic  dressings  and 
compression. 

Scurvy  can  be  prevented  entirely  by  employing  a  proper 
diet,  and  maintaining  cleanliness  and  hygienic  conditions.^ 

The  following  agents  are  believed  to  be  especially  useful 
as  preventatives  :  fresh  meat,  lemon-juice,  cider,  vinegar,  milk, 
eggs,  onions,  cranberries,  cabbages,  pickles,  potatoes,  and 
lime-juice. 

Infantile  scurvy  may  exist  alone  or  with  rickets.  It  oc- 
curs most  often  in  the  children  of  the  well-to-do,  those  who 
have  been  brought  up  on  artificial  foods.  It  occurs  between 
the  eighth  and  eighteenth  months.  The  child  is  anemic, 
suffers  from  gastro-intestinal  disorders,  spongy  gums,  weak- 

'  American  Text-Book  of  Szirgejy. 
*  Ibid. 


co.vrrswxs.  203 

ness  of  the  legs,  general  muscular  tenderness,  night-sweats, 
and  often  febrile  attacks  (Rotch).  There  may  be  bleeding 
beneath  the  skin  (blue  spots ),  bloody  unne  and  stools,  bleeding 
into  joints,  viscera,  or  muscles.  A  subperiosteal  hemorrhage 
is  veiy  dense,  is  tender,  is  fusiform  in  outline,  and  does  not 
fluctuate.  It  is  sometimes  mistaken  for  sarcoma.  The  limb 
attacked  is  flexed,  and  the  child  will  not  move  it.  Separation 
of  an  epiphysis  ma}'  result  from  hemorrhage  between  it  and 
the  bone. 

Treatment. — Give  orange-juice,  grape-juice,  meat-juice, 
scraped  apples,  potatoes,  nourishing  food,  tonics,  and  anti- 
septic mouth-washes. 

XV.  CONTUSIONS   AND   WOUNDS. 

Contusions. — A  contusion  or  bruise  is  a  subcutaneous 
laceration,  the  skin  abo\'e  it  being  uninjured  or  damaged 
without  a  surface-breach  and  blood  being  effused.  In  intra- 
abdominal contusions  the  skin  of  the  abdomen  is  fre- 
quently not  damaged.  In  contusion  of  structures  overlying 
a  bone  the  skin  suffers  with  the  deeper  structures.  If  a 
large  vessel  is  ruptured,  hemorrhage  is  profuse  and  much 
blood  gathers  in  the  tissue.  If  only  small  vessels  suffer, 
hemorrhage  is  moderate.  An  ecchyjiiosis  is  diffuse  hemor- 
rhage over  a  large  area,  the  blood  lying  in  the  spaces  of  the 
subcutaneous  or  submucous  areolar  tissue.  A  liCDiatouia  is  a 
blood-tumor  or  a  circumscribed  hemorrhage,  the  blood  lying 
in  a  distinct  caxity  in  the  tissues.  x\  v^ry  small  ecchymosis 
is  known  as  a  petechia ;  a  very  large  ecchymosis  is  called  a 
suffusion  or  extravasation.  In  very  severe  contusions,  tissue 
vitality  may  be  destroyed  or  so  seriously  impaired  that  gan- 
grene follows.  Suppuration  rarely  occurs,  but  occasionally 
does  so.  and  is  most  apt  to  in  drunkards  or  those  of  dilapi- 
dated constitution.  When  hemorrhage  arises  in  the  tissues 
after  a  contusing  force  it  soon  ceases  unless  a  verv^  consider- 
able vessel  is  ruptured.  The  arrest  of  hemorrhage  is  brought 
about  by  the  resistance  of  the  tissues,  the  contraction  and 
retraction  of  the  vessels,  by  coagulation  of  blood,  and  in  some 
cases  of  severe  injun*  coagulation  is  favored  by  syncope 
(page  337).  Blood  in  the  tissues,  as  a  rule,  soon  coagulates, 
the  fluid  elements  being  absorbed  and  the  red  corpuscles 
breaking  up  and  setting  free  pigment,  which  pigment  may  be 
carried  away  from  the  seat  of  injur}'  or  ma}^  cn'stallize  and 
remain  there  as  hematoidin.  In  some  cases  inflammation 
occurs   about  the    extravasated  blood,  a  capsule   of  fibrous 


204  CONTUSIONS  AND    WOUNDS. 

tissue  being  formed,  and  the  blood  being  slowly  absorbed,  or 
the  fluid  elements  remaining  unabsorbed  (blood-cyst),  or  the 
blood  becoming  thicker  and  thicker,  finally  calcifying. 
Blood  in  serous  sacs  (joints,  pleura,  pericardium)  coagulates 
very  slowly.  As  blood  is  being  absorbed  it  undergoes 
chemical  changes  and  color-changes  ensue,  the  part  being  at 
first  red  and  then  becoming  purple,  black,  green,  lemon,  and 
citron.  The  .stain  following  a  contusion  is  most  marked  in 
the  most  dependent  area.  After  a  bruise  of  the  periosteum 
a  blood-clot  forms,  much  tissue-induration  occurs,  and  a 
hard  edge  can  be  detected  by  palpation. 

Symptoms. — The  symptoms  are  tenderness,  swelling,  and 
numbness,  followed  by  some  aching  pain  or  a  feeling  of  sore- 
ness. The  pain  rarely  persists  beyond  the  first  twenty-four 
hours.  Discoloration  appears  quickly  in  superficial  con- 
tusions, but  only  after  days  in  deep  ones.  In  some  regions, 
the  scalp,  for  instance,  it  can  scarcely  be  detected  ;  in  others, 
as  in  the  eyelid  and  vulva,  discoloration  is  early,  widespread, 
and  marked.  Discoloration  is  ven,^  marked  in  regions  where 
loose  cellular  tissue  abounds  (eyelids,  prepuce,  scrotumj.  The 
discoloration  is  at  first  red,  and  becomes  successively  purple, 
black,  green,  lemon,  and  citron.  The  swelling  is  first  due  to 
blood,  and  is  added  to  by  inflammatory  exudation.  In  a  more 
severe  contusion  a  hematoma  may  form.  In  the  skin  over  a 
superficial  hematoma  there  is  discoloration  ;  in  the  skin  over 
a  deep  hematoma  there  is  no  discoloration.  A  recent  hema- 
toma fluctuates,  but  gradually,  because  of  cell-proliferation,  the 
edge  becomes  hard  and  the  center  continues  to  fluctuate.  The 
mass  gradually  grows  smaller  and  finally  disappears.  A  hema- 
toma of  the  scalp  may  be  mistaken  for  depressed  fracture  of 
the  skull  (p.  658).  It  may  also  be  mistaken  for  an  abscess, 
but  differs  from  it  in  the  absence  of  inflammator}^  signs.  It 
occasionally,  though  rarely,  suppurates.  In  a  case  in  which 
suppuration  occurs  an  abrasion,  which  may  be  very  minute, 
often  exists  on  the  skin.  In  any  severe  contusion  there  is 
considerable  and  possibly  grave,  or  even  fatal,  shock. 

Treatment. — In  a  severe  injur}^  bring  about  reaction  from 
the  shock.  Local  treatment  consists  in  rest,  elevation,  and 
compression  to  arrest  bleeding,  antagonize  inflammation,  and 
control  swelling.  Cold  is  useful  early  in  most  cases,  but  it  is 
not  suited  to  very  severe  contusions  nor  to  contusions  in  the 
debilitated  or  aged,  as  in  such  cases  it  may  cause  gangrene. 
In  very  severe  contusions  employ  heat  and  stimulation. 
When  inflammation  is  subsiding  after  a  contusion,  massage 
and  inunctions  of  ichthyol  should  be  employed.     Massage 


WOCXDS.  20  = 


and  passive  motion  are  imperatively  needed  after  contusion 
of  a  joint.  A  contusion  should  never  be  incised  unless  the 
amount  of  blood  is  large  and  a  distinct  cavity  exists,  or  hem- 
orrhage continues,  infection  takes  place,  a  lump  remains 
for  some  weeks,  or  gangrene  is  threatened.  If  the  amount  of 
blood  is  very  large  and  a  distinct  ca\-it)'  exists,  aspiration  or 
incision  lessens  the  danger  of  fat-embolism.  For  persistent 
bleeding  freely  lay  open  the  contused  area,  turn  out  clots, 
ligate  vessels,  insert  drainage-strands  or  a  tube,  and  close  the 
wound.  If  gangrene  is  feared,  make  incisions  and  apph-  heat 
to  the  part.  If  a  slough  forms,  employ  antiseptic  fomenta- 
tions. The  constitutional  treatment  for  contusion,  after  the 
patient  has  reacted  from  shock,  is  the  same  as  that  for  inflam- 
mation. 

Wounds. — A  wound  is  a  breach  of  surface-continuity 
effected  by  a  sudden  mechanical  force.  Wounds  are  divided 
into  open  and  subcutaneous,  septic  and  aseptic,  incised,  con- 
tused, lacerated,  punctured,  gunshot,  and  poisoned. 

The  local  phenomena  of  wounds  are  pain,  hemor- 
rhage, loss  of  function,  and  gaping  or  retraction  of  edges. 

Paiji  is  due  to  the  injur}-  of  ner\-es,  and  it  varies  according 
to  the  situation  and  the  nature  of  the  injur>\  It  is  influ- 
enced by  temperament,  excitement,  and  preoccupation.  It 
may  not  be  felt  at  all  at  the  time  of  the  injur}-.  At  first  it 
is  usually  acute,  becoming  later  dull  and  aching.  In  an  asep- 
tic wound  the  pain  is  usualh'  slight,  but  in  an  infected  wound 
it  is  always  severe. 

The  nature  and  amount  of  hnnorrhage  van.'  with  the  state 
of  the  system,  the  vascularity  of  the  part,  and  the  variety  of 
iniur}-. 

'  Loss  of  function  depends   on   the   situation   and  extent  of 

the  injury. 

Gaping  or  retraction  of  edges  is  due  to  tissue-elasticit}', 
and  varies  according  to  the  tissues  injured  and  the  direction, 
nature,  and  extent  of  the  wound. 

The  constitutional  condition  after  a  severe  injur}-  is  a 
state  known  as  shock,  which  is  a  sudden  depression  of  the 
vital  powers  arising  from  an  injur}-  or  a  profound  emotion 
acting  on  the  ner\-e-centers  and  inducing  vasomotor  paresis 
and  paralysis  of  the  sympathetic  in  the  abdomen,  the  blood 
accumulating  in  the  abdominal  vessels  and  the  amount  of 
circulating  blood  being  much  diminished.  In  shock  the 
abdominal  veins  are  greatly  distended  and  the  other  veins  of 
the  body  may  also  be  overfull,  the  arteries  contain  less  blood 
tKan  normal,'  and  an  insufficient  amount  of  blood  is  sent  to 


206  CONTUSIONS  AND    WOUNDS. 

the  vital  centers  in  the  brain.  The  term  collapse  is  used  by- 
some  to  designate  a  severe  condition  of  shock,  and  is  em- 
ployed by  others  as  a  name  for  a  condition  of  shock  produced 
by  mental  disturbance  rather  than  by  physical  injury.  Shock 
may  be  slight  and  transient,  it  may  be  severe  and  prolonged, 
and  it  may  even  produce  almost  instant  death.  Sudden  death 
from  shock  is  due  to  reflex  stimulation  of  the  pneumogastric 
nuclei  and  arrest  of  cardiac  action.  It  is  known  as  death  by 
InFiBiEon.  Shock  is  more  severe  in  women  than  in  men,  in 
the  nervous  and  sanguine  than  in  the  lymphatic,  in  those 
weakened  by  suffering  than  in  those  who  are  strangers  to 
illness.  It  is  predisposed  to  by  fear,  by  disease  of  the  kid- 
neys, diabetes,  chronic  cardiac  disease,  and  alcohohsm. 
Injuries  of  nerves,  of  the  intrathoracic  viscera,  of  the  intra- 
abdominal viscera,  of  the  urethra,  or  of  the  testicle  produce 
extreme  shock.  Anything  which  extracts  the  body-heat 
favors  the  development  of  shock  (exposure  to  cold  air,  insuf- 
ficient covering,  chilling  the  body  by  solutions  or  wet  towels). 
Cerebral  concussion  is  shock  plus  other  conditions.  Sudden 
and  profuse  hemorrhage  causes  shock  ;  so  does  prolonged 
anesthetization.  Great  shock  may  occur  after  the  removal 
of  a  large  tumor  or  a  quantity  of  fluid  from  the  abdomen. 
In  such  a  case  shock  is  brought  about  by  the  sudden  removal 
of  pressure  and  the  consequent  rapid  distention  of  intra- 
abdominal veins. 

Symptoms. — The  symptoms  of  ordinary  shock  (torpid  or 
apathetic  shock)  are  subnormal  temperature ;  irregular, 
weak,  rapid,  and  compressible  pulse;  cold,  pallid,  clammy, 
or  profusely  perspiring  skin  ;  shallow  and  irregular  respira- 
tion ;  and  a  tendency  to  urinary  suppression.  Consciousness 
is  usually  maintained,  but  there  is  an  absence  of  mental  orig- 
inating power,  the  injured  person  answering  when  spoken 
to,  but  volunteering  no  statements  and  lying  with  partly 
closed  lids  and  expressionless  countenance  in  any  position  in 
which  he  may  be  placed.  The  pupils  are  dilated  and  react 
but  slowly  to  light.  The  sphincters  are  relaxed.  Paints 
slightly  or  not  at  all  appreciated.  Nausea  is  absent  and  vom- 
iting may,  as  in  concussion,  presage  reaction.  Gastric 
regurgitation,  after  a  considerable  duration  of  shock  is  not 
unusual,  and  is  a  bad  omen.  Shock  is  not  rarely  followed 
by  suppression  of  urine.  Whereas  the  victim  of  shock  is 
usually  stupid  and  indifferent,  he  may  become  delirious. 
If  delirium  arises,  the  condition  is  very  grave.  Travers 
called  shock  with  delirium  erithistic  or  delirious  shock.  As 
a  matter  of  fact,  such  a   state  is  not  genuine  shock,  but  is 


WOUNDS. 


207 


either  a  traumatic  or  a  toxic  delirium.  It  is  usually  due  to 
uremia  or  sepsis.  Delirious_shock  arises  after  a  person  has 
been  bitten  by  a  poisonous  snake.  Many  years  ago  Travers 
described  a  secondary  or  delayed  form  of  shock,  which  comes 
on  several  hours  after  an  injury  or  violent  emotional  dis- 
turbance. This  form  of  shock  is  seen  not  unusually  in  those 
who  have  passed  through  a  railroad  accident.  It  may  be  a 
sign  of  hemorrhage,  and  is  sometimes  met  with  after  the 
administration  of  ether  or  chloroform. 

Diag-nosis. — Concealed  hemorrhage  is  difficult  to  separate 
from  shock.  It  produces  impairment  of  vision  (retinal  ane- 
mia), irregular  tossing,  frequent  yawning,  great  thirst,  nausea, 
and  sometimes  convulsions.  In  shock  the  hemoglobin  is 
unaltered  ;  in  hemorrhage  it  is  enormously  reduced  (Hare 
and  Martin).  In  hemoxrhage  recurrent  attacks  of  syncope 
are  met  with.  In  pure  shock  such  attacks  do  not  occur.  'In 
concealed  hemorrhage  the  abdomen  may  exhibit  physical 
signs  of^a  rapidly  increasing  collection  of  fluid.  Shock  "and 
hemorrhage  are  often  associated.  The  essential  character- 
istic of  shock  is  sudden  onset,  which  separates  it  distinctly 
froni  exhaustion.  It  arises  at  a  much  earlier  period  after  an 
injury  than  does  fat-embohsm. 

The  Prevention  of  Shock  m  Operations. — Examine  the 
patient  with  care  before  operating,  giving  special  attention  to 
the  condition  of  the  kidneys.  If  the  condition  of  the  patient 
leads  us  to  fear  that  there  will  be  dangerous  shock,  do  not 
purge  him  severely  before  operation,  and  just  previous  to 
operation  give  a  rectal  injection  of  hot  saline  fluid.  It  is  a 
good  plan  in  such  cases  ""to  give  a  hypodermatic  injection  of 
g^-  s  of  morphin  twenty  minutes  before  operation.  Give  as 
Httle  ether  as  possible.  Cover  every  part  but  the  field  of 
operation  with  hot  blankets  and  put  cans  of  hot  water  about 
the  patient,  or  put  him  on  a  bed  composed  of  hot-water  pipes 
covered  with  blankets.  Operate  as  rapidly  as  is  consistent 
with  safety  and  thoroughness. 

Treatment. — In  treating  ordinary  apathetic  shock  raise_the 
feet  and  lower  the  head,  unless  this  position  causes  cyanosis. 
At  least  place  the  head  flat  and  the  body  recumbent.  Wrap 
the  patient  in  hot  blankets  and  surround  him  with  hot  bottles, 
hot  bricks,  hot-water  bags,  or  cans  of  hot  water.  Always 
wrap  a  can,  a  bottle,  or  a  bag  in  flannel,  to  avoid  burning  the 
patient.  Give  hypodermatic  injections  of  ether.-^  brandy, 
strychnin,  digitalis,  or  atropin,  or  inhalations  of  amyl  nitrite. 
Strychnin  can  be  used  in  large  doses ;  gr.  -^-^  can  be  given 
every  ten  or  fifteen  minutes  until  three  doses  have  been  taken. 


208  CONTUSIONS  AND    WOUNDS. 

If  the  skin  is  very  moist,  atropin  is  indicated ;  it  can  be 
given  alone  or  combined  with  strychnin.  Senn  recommends 
the  hypodermatic  injection  of  sterile  camphorated  oil,  a 
syringeful  every  fifteen  minutes  until  reaction  begins.  Inhala- 
tion of  oxygen  is  often  of  much  service,  and  artificial  respira- 
tion may  be  necessary.  Opiates  are  contraindicated  in  shock. 
Mustard  plasters  should  be  placed  over  the  heart,  spine,  and 
shins.  The  use  of  hot  and  stimulating  rectal  enemata  is  veiy 
important.  The  rectum  may  absorb  fluids  when  the  stomach 
refuses  to  do  so.  Enemata  of  hot  normal  salt  solution  are 
very  beneficial  (.enteroclysis).  The  tube  is  carried  into  the 
sigmoid  flexure  and  the  injection  is  introduced  so  as  to  dis- 
tend the  colon.  A  turpentine  enema  is  useful.  An  enema 
of  hot  coffee  and  whiskey  is  very  valuable.  In  severe  cases 
of  shock  bandage  the  extremities.  Bandaging  for  the  relief 
of  shock  is  called  autotransfusion.  This  procedure  enables 
the  body  to  utilize  to  the  best  advantage  the  small  amount  of 
circulating  blood,  and  send  most  of  it  to  the  brain,  where  it 
will  maintain  the  activity  of  the  vital  centers  and  keep  up 
circulation  and  respiration.  For  this  purpose  ordinary 
muslin  bandages  may  be  used,  or  gauze  bandages,  or  the 
bandages  of  Esmarch.  Abdominal  massage  helps  drive  out 
the  imprisoned  blood,  and  after  massage  sets  free  the 
abdominal  blood  apply  a  compress  and  binder.  Hy- 
podermoclysis  is  of  great  value.  Insert  an  aspirator-tube 
into  the  cellular  tissue  of  the  buttock,  loin,  or  scapular  re- 
gion, cleansing  the  part  first.  The  tube  is  attached  to  a 
fountain-syringe,  which  is  filled  with  normal  salt  solution, 
and  is  hung  at  a  height  of  two  or  three  feet  above  the  bed. 
In  an  hour's  time  a  pint  or  more  of  fluid  will  enter  the  tis- 
sue and  be  absorbed.  In  very  dangerous  cases  infuse 
salt  solution  into  a  vein,  make  artificial  respiration,  and 
stimulate  the  diaphragm  with  a  galvanic  current.  If  shock 
comes  on  during  an  operation,  the  operation  mu.st  be 
hurried  or  even  stopped,  and  proper  treatment  must  be 
instituted  at  once.  The  anesthetizer  should  give  very 
little  ether  when  shock  becomes  at  all  evident.  Should  we 
operate  during  shock  ?  We  should  only  do  so  when  death 
without  instant  operation  is  inevitable.  We  must  operate,  if 
it  is  necessary  to  do  so,  to  arrest  hemorrhage,  to  relieve 
.strangulated  hernia,  intestinal  obstruction,  obstruction  of  the 
air-passages,  compound  fractures  of  the  skull,  extravasated 
urine  or  intraperitoneal  extravasations  from  ruptured  viscera. 
If  hemorrhage  can  be  temporarily  controlled  by  pressure  or 
a  clamp,  so  much  the  better,  and  the  permanent  arrest  can  be 


TREATMEXT  OF   U'OUXDS.  209 

effected  after  the  reaction  from  shock.  It  is  not  wise,  in  the 
author's  opinion,  to  amputate  during  shock.  A  tourni- 
quet or  Esmarch  bandage  should  be  appHed,  and  attempts 
be  made  to  bring  about  reaction,  and  when  reaction  is  ob- 
tained the  amputation  should  be  performed.  It  is  only  just 
to  say  that  some  eminent  surgeons  oppose  this  rule.  Ros- 
well  Park  says  that  "  shock  is  often  alle\-iated  by  the  prompt 
removal  of  mutilated  limbs  which,  when  still  adherent  to  the 
trunk,  seem  to  perpetuate  the  condition."  The  same  teacher 
believes  in  operating  at  once  upon  severe  compound  fractures.^ 
After  every  operation  keep  careful  watch  upon  the  amount 
of  urine  passed,  see  to  it  that  the  patient  takes  sufficient  fluid, 
and  if  the  urine  becomes  scanty  put  a  hot-water  bag  over  the 
kidneys,  give  diuretics  and  hot  saline  enemata.  If  the  con- 
dition is  not  soon  benefited,  infuse  hot  saline  fluid  into  a  vein. 
Post-operative  suppression  of  urine  is  ahnost  invariably  fatal. 
Dela\'ed  shock  is  treated  in  the  same  manner  as  apathetic  shock 
if  hemorrhage  can  be  excluded.  If  hemorrhage  is  the  cause, 
the  bleeding  must  be  stopped.  If  deHrious  shock  is  due  to  sep- 
sis, the  treatment  is  that  of  sepsis.  If  it  is  a  ner\-ous  deJirium, 
give  morphin  and  other  sedatives.  If  due  to  uremia  the  treat- 
ment is  obvious. 

Fat-embolism. — (See  p.  172.) 

Fever. — (See  Fevers,  p.  115.) 

Treatm.ent  of  Wounds. — All  wounds,  other  than  those 
made  b}-  the  surgeon,  are  regarded  as  infected.  The  rules 
for  treating  such  wounds  are — (i)  arrest  hemorrhage;  (2) 
bring  about  reaction  ;  (3)  remove  foreign  bodies  ;  (4)  asepti- 
cize ;  (5)  drain,  coaptate  the  edges,  and  dress  ;  and  (6)  secure 
rest  to  the  part  and  combat  inflammation.  Constitutionally, 
allay  pain,  secure  sleep,  maintain  the  nutrition,  and  treat  in- 
flammatory' conditions. 

Arrest  of  Hemorrhage. — To  arrest  hemorrhage  the  bleed- 
ing point  must  be  controlled  by  an  Esmarch  band  or  digital 
pressure  until  ready  to  be  grasped  with  forceps  ;  it  is  then 
caught  up  and  tied  with  catgut  or  aseptic  silk.  Slight  hemor- 
rhage stops  spontaneously  on  exposure  to  air.  and  moderate 
hemorrhage  ceases  after  the  vessels  are  clamped  for  a  time.  An 
injured  vessel  when  not  of  the  smallest  size  must  be  ligated,even 
if  it  has  ceased  to  bleed.  Capillar}-  oozing  is  checked  by  hot 
water  and  compression.  If  a  large  arten,-  is  di\"ided  in  a  limb, 
apply  a  tourniquet  before  ligating  (see  Wounds  of  Vessels). 

Bringing  about  of  Reaction. — ( See  Shock.) 

Reinoval  of  Foreign  Bodies. — Remove  all  foreign  bodies 

1   Park's  Stirgery  by  Amencan  Aitthors. 
14 


2IO  CONTUSIONS  AND    WOUNDS. 

visible  to  the  eye  (splinters,  bits  of  glass,  portions  of  cloth- 
ing, gun-wadding,  grains  of  dirt,  etc.)  with  forceps  and  a 
stream  of  corrosive-sublimate  solution,  sterile  water,  or  normal 
salt  solution.  In  a  lacerated  or  contused  wound  portions  of 
tissue  injured  beyond  repair  should  be  regarded  as  foreign 
bodies  and  be  removed  with  scissors. 

Cleaning  the  Wound. — To  clean  the  wound  scrub  the  area 
around  it  with  ethereal  soap,  green  soap,  or  castile  soap,  wash 
with  water,  scrub  with  alcohol,  and  then  with  corrosive-sub- 
limate solution  (i  :  looo).  If  the  surface  is  hairy,  it  must  be 
shaved  before  the  scrubbing.  An  accidental  wound  is  in- 
fected, and  must  be  well  washed  out  with  an  antiseptic  solu- 
tion. A  clean  wound  made  by  the  surgeon  need  not  be 
irrigated ;  in  fact,  irrigation  with  an  antiseptic  fluid  leads  to 
necrosis  of  tissues,  causes  a  profuse  flow  of  serum,  and  ne- 
cessitates drainage.  If  clots  have  gathered  in  a  wound,  they 
must  be  removed,  as  their  presence  will  prevent  accurate  co- 
aptation of  the  edges.  In  an  infected  wound  they  are  washed 
out  with  a  stream  of  corrosive-sublimate  solution.  In  a  clean 
wound  they  are  washed  out  with  hot  salt  solution.  If  dirt  is 
ground  into  a  wound,  as  is  often  seen  in  crushes,  pour  sweet 
oil  into  the  wound,  rub  it  into  the  tissues,  and  scrub  the  wound 
with  ethereal  soap.  The  oil  entangles  the  dirt,  and  the  soap 
and  water  remove  both  oil  and  dirt.  After  the  rough  cleans- 
ing irrig-ate  with  corrosive-sublimate  solution.  In  some  cases, 
especially  in  bone-injuries,  it  is  necessary  to  scrape  the 
wound  with  a  curet.  If  a  fissure  of  the  skull  is  infected, 
enlarge  the  fissure  with  a  chisel  in  order  to  clean  it.  In  a 
badly  infected  wound  one  of  the  most  valuable  agents  for  use 
in  producing  disinfection  is  pure  carbolic  acid.  After  clean- 
ing the  wound,  it  is  necessary  in  certain  regions  to  examine 
in  order  to  determine  if  tendons  or  considerable  nerves  have 
been  cut.  If  such  structures  have  been  divided,  they  must 
be  sutured  with  fine  silk,  chromic  gut,  or  kangaroo-tendon. 

Drainage,  Closure  and  Dressing. — Superficial  wounds  re- 
quire no  special  drainage,  as  some  wound-fluid  will  find  exit 
between  the  stitches  and  the  rest  will  be  absorbed.  A  large 
or  deep  wound  requires  free  drainage  for  at  least  twenty-four 
hours  by  means  of  a  tube,  strands  of  horse-hair,  silk,  or 
catgut,  or  bits  of  iodoform  gauze.  An  infected  wound  must 
invariably  be  drained.  Good  drainage  may,  to  a  considerable 
extent,  compensate  for  imperfect  antisepsis.  If  capillary 
drains  be  employed,  apply  a  moist  dressing.  Approximate 
the  edges  with  interrupted  sutures  of  silk  or  silkworm-gut  if 
the  wound  is    deep    and  considerable    tension  is    inevitable. 


TREATMENT  OF   WOUNDS.  211 

Catgut  is  used  for  superficial  wounds  and  for  those  where 
tension  is  sHght.  If  there  is  decided  tension,  silver  wire  may 
be  used.  In  very  deep  wounds  buried  sutures  must  be  used. 
These  sutures  may  consist  of  absorbable  material  (kangaroo- 
tendon  or  catgut)  or  unabsorbable  material  (silver  wire).  If 
the  wound  is  infected,  dress  with  moist  antiseptic  gauze.  If 
it  is  not  infected,  dress  it  with  dry  sterile  gauze.  The  custom 
once  was  to  cover  the  gauze  with  a  rubber-dam  to  diffuse 
the  fluids,  but  we  now  prefer  to  omit  the  rubber-dam  and 
use  plentiful  dressings.  A  dry  dressing  absorbs  wound-fluids 
quickly  and  is  less  likely  to  become  infected.  Change  the 
dressings  in  twenty-four  hours,  or  sooner  if  they  become 
soaked  with  discharge.  Dressings  are  changed  for  cause, 
but  not  according  to  scheduled  time.  They  must,  of  course, 
be  changed  when  they  become  soaked  with  wound-fluid,  and 
soaking  may  occur  in  a  few  hours,  but  may  not  .occur  for 
days.  As  long  as  temperature  remains  good,  the  wound  free 
from  pain,  and  the  dressing  not  wet  with  discharge,  it  can  be 
left  in  place  unless  removal  is  necessary  to  take  out  a 
drainage-tube.  If  pus  forms,  open  the  wound  at  once. 
Many  surgeons  sprinkle  wounds  before  approximation  and 
wound-surfaces  after  approximation  with  a  drying-powder. 
These  powders  are  of  great  use  in  infected  wounds,  but  are 
not  necessary  in  clean  wounds.  Among  the  substances  em- 
ployed are  salicylic  acid,  boracic  acid,  calomel,  acetanilid, 
aristol,  iodoform,  subiodid  of  bismuth,  and  glutol.  In  large 
wounds  which  cannot  be  approximated,  it  is  occasionally 
advisable  to  skin-graft  by  Thiersch's  method.  A  small 
wound  which  cannot  be  sutured  is  dusted  with  an  anti- 
septic powder  and  dressed.  A  granulating  wound  is 
dressed  as  is  a  healing  ulcer.  A  sloughing  wound  is  opened, 
is  dusted  with  iodoform  or  acetanilid,  and  is  dressed  with  hot 
antiseptic  fomentations. 

Rest. — Severe  wounds  require  the  confinement  of  the  pa- 
tient to  bed.  Bandages,  splints,  etc.,  are  used  to  secure  rest. 
The  methods  of  combating  inflammation  have  previously 
been  set  forth. 

Constitutional  Treatment. — Bring  about  reaction  from  de- 
pression, but  prevent  undue  reaction.  Feed  the  patient  well, 
stimulate  him  if  necessary,  attend  to  the  bowels  and  bladder, 
secure  sleep,  and  allay  pain.  Watch  for  complications,  namely, 
inflammation,  suppuration,  gangrene,  tetanus,  and  erysipelas. 
Observe  the  temperature  closely ;  it  may  be  a  danger-signal 
of  urgent  importance. 

Incised  Wounds. — An   incised  wound  is  a  clean  c7it  in- 


212 


CONTUSIONS  AND    WOUNDS. 


flicted  by  an  edged  instrument.  Only  a  thin  film  of  tissue 
is  so  devitalized  that  it  must  die.  These  wounds  have  the 
best  possible  chance  of  union  by  first  intention. 

The  pain  may  be  very  severe  ;  but  if  the  instrument  is  sharp 
and  used  quickly  it  may  be  trivial.  The  pain  is  less  severe 
than  that  caused  by  some  other  varieties  of  wounds.  The 
acute  pain  does  not  last  long,  and  is  followed  by  smarting. 
The  hemorrhage  is  profuse,  varying,  of  course,  with  the  region 
cut.  Bleeding  from  the  scalp  is  violent,  because  there  are 
numerous  vessels  which  lie  in  fibrous  tissue  and  cannot  retract 
nor  contract.  The  edges  of  incised  wounds  retract  because  of 
tissue-elasticity,  and  the  wound  "  gaps."  If  the  skin  or  fasciae 
are  divided  at  a  right  angle  to  the  muscle  beneath,  there  is 
wide  gaping.  If  the  cut  is  parallel  to  the  muscle-fibers,  the 
gaping  is  slight. 

When  the  skin  is  violently  pulled  upon,  it  tends  to  split  in 
a  certain  line.  Langer  and  Kocher  speak  of  this  as  the  line 
of  cleavage,  and  point  out  the  direction  of  these  lines  in 
various  situations.  A  cut  across  the  line  of  cleavage  is  fol- 
lowed by  wide  gaping.  A  cut  in  the  direction  of  the  line  of 
cleavage  produces  slight  gaping,  and  is  followed  by  a  trivial 
scar. 

When  a  muscle  is  cut  across,  the  wound-edges  widely 
separate.  When  a  tendon  is  completely  cut  across,  extensive 
separation  occurs. 

Treatment. — According  to  general  principles  arrest  hemor- 
rhage and  asepticize. 

Examine  the  wound  carefully  to  see  if  a  nerve,  a  tendon, 
or  a  muscle  is  divided,  and  if  such  injury  is  discovered  suture 


The  right  way. 


Fig.  56. — Interrupted  suture. 


\M^  The  wrong  way. 


Fig.  55. — The  interrupted  suture  (after  Bryant) 


Fig.  57. — Continuous  suture. 


at  once.     If  the  wound  is  extensive  or  deep,  it  may  be  neces- 
sary to  use  buried  sutures  in  order  to  keep  the  sides  of  the 


TREATMENT  OF   WOUNDS. 


213 


wound  in   contact.     If  the  surface  of  a  wound  is  approxi- 
mated,  but   the   depths   are  not,  the   dead   space   or  cavity 


Fig.  5S. — Ford's  suture:  a  square  knot, 
a  single  knot,  a  double  or  friction  knot,  and 
the  first  method  of  passing  the  needle  to  tie 
a  single  knot  immediately. 


Fig.  59. — Ford's  suture  :  showing  two 
square  knots,  a  single  knot,  and  the  method 
of  completing  a  square  knot. 


Fig.  60. — Halsted's  subcuticular  sutiu-e. 


Fig.  61. — The  quilled  suture. 


becomes    filled    with    fluid,    and    infection    almost    certainly 
occurs.     If  buried  sutures  have  not  been  used,  such  a  cavity 


214 


CONTUSIONS  AND    IVOLNDS. 


must  be  obliterated  by  the  judicious  application  of  pressure 
upon  the  surface.  This  is  secured  by  the  adaptation  of  a 
mass  of  loose  or  fluffed-up  gauze,  and  the  firm  application 
of  a  bandage  or  binder.  An  incised  wound  is  usually  closed 
with  interrupted  sutures  (Figs.  55  and  56).  In  adjusting  the 
sutures,  see  that  the  edges  of  the  wound  are  not  inverted, 
but  are  neatly  adjusted,  and  that  the  knot  does  not  lie  upon 
the  wound-line,  but  rests  to  the  side  of  it.  Tie  the  stitches 
firmly  but  not  tightly.  If  a  stitch  is  tied  too  tightly  it  will 
make  a  furrow,  as  shown  in  Fig.  55,  and  undue  tightness 
is  sure  to  cause  necrosis,  and  is  often  productive  of  a  stitch-ab- 
scess. A  silk  suture  and  a  catgut  suture  should  be  tied  with 
the  reef  knot ;  a  suture  of  silkworm-gut  should  be  tied  with  a 
surgeon's  knot.  If  a  wound  is  on  the  face,  particular  care 
must  be  employed  in  closing  it,  in  order  to  limit  the  amount 
of  disfigurement.  In  a  clean  wound  stitches  can,  as  a  rule, 
be  removed  in  from  six  to  eight  days.     In  a  large  wound 

one-half  the  stitches  are  removed 
at  one  sitting,  and  in  a  day  or  two 
the  rest  are  removed.  Stitches  are 
promptly  removed  if  they  begin  to 
cut  out  or  if  infection  occurs. 

The  old  continued  suture  (Fig.  57) 


Fig.  62. — Button  suture. 


Fig.  63. — The  twisted  suture. 


is  rarely  used  for  skin-wounds  at  the  present  time.  This 
suture  is  employed  to  suture  the  dura  after  division,  to 
suture  the  two  layers  of  pleura  together  before  an  abscess 
of  the  lung  is  opened,  to  suture  the  peritoneum  after  lapa- 
rotomy, and  to  suture  the  mucous  membrane  after  certain 
operations  upon  the  stomach.  The  continued  suture  is  shown 
in  Figs.  57-59- 

Halsted's  subcuticular  stitch  (Fig.  60)  makes  a  most  per- 
fect closure  of  the  skin-wound,  and  is  followed  by  the  smallest 
possible  scar.  It  is  only  used  in  wounds  which  are  almost 
certainly  clean,  as  those  made  by  the  surgeon,  and  in  wounds 
which  do  not  require  drainage.     The  suture  is  of  silver  wire 


TREATMENT  OF   WOUNDS.  21  5 

caught  upon  a  Hagedorn  needle  and  passed  through 
the  corium  on  each  side  of  the  wound,  as  shown  in  Fig.  60. 
The  needle  must  be  held  in  the  bite  of  a  needle-holder. 
When  the  suture  has  been  passed  the  ends  are  pulled  upon, 
and  the  skin-wound  closes  neatly. 

Halsted's  suture  does  not  penetrate  the  skin  ;  hence,  in 
passing  it  the  white  staphylococcus  is  not  carried  through 
stitch-holes  and  into  the  wound,  an  accident  which  might  be 
followed  by  infection  of  a  stitch-hole  or  even  of  the  wound. 
When  it  is  desired  to  withdraw  this  suture,  take  one  end  in 
the  bite  of  a  forceps,  cut  it  off  short  with  scissors,  and  pull 
steadily  upon  the  other  end. 

In  very  deep  wounds  or  wounds  in  which  there  is  much 
tension  after  approximation  the  quilled  suture  (Fig.  61),  or 
the  button-suture  (Fig.  62)  may  be  used.  The  twisted  suture, 
or  harelip  suture,  is  shown  in  Fig.  63. 

Problems  of  drainage,  dressing,  etc.,  are  discussed  on  page 
210. 

If  infection  occurs,  the  wound  becomes  swollen,  tender, 
painful,  and  discolored,  and  the  temperature  of  the  patient 
soon  becomes  elevated.  In  such  a  condition  cut  the  stitches, 
disinfect,  and  drain. 

Contused  and  Lacerated  Wounds. — A  contused  wound 
results  from  a  blow  or  a  squeeze  which  bruises  and  crushes 
the  tissues  and  splits  or  ruptures  the  skin.  It  is  a  common 
injury  when  force  is  applied  to  tissues  over  a  bone.  The 
blow  of  a  blackjack  will  cause  either  a  contusion  or  a  con- 
tused wound  of  the  scalp.  A  contused  wound  is  irregular  in 
outline,  with  jagged  edges,  and  is  surrounded  by  a  broad  zone 
of  contusion. 

A  lacerated  wound  results  from  tearing  apart  of  the  tissues. 
It  too  is  irregular  and  jagged,  and  is  accompanied  by  more  or 
less  contusion.  A  brush-burn  is  a  contused-lacerated  wound 
due  to  friction.  Both  lacerated  and  contused  wounds  con- 
tain masses  of  partly  detached  and  damaged  tissue,  the 
vitality  of  which  is  endangered.  Hence,  such  wounds  are  apt 
to  slough,  frequently  suppurate,  and  are  occasionally  followed 
by  cellulitis  or  even  by  gangrene.  There  is  more  danger 
of  tetanus  than  in  incised  wounds.  In  contused  and  lacerated 
wounds  the  edges  are  discolored  and  cold  to  the  touch,  and 
there  is  little  primary  hemorrhage.  There  is  considerable 
danger  of  secondary  hemorrhage  if  large  vessels  have  been 
bruised.  In  wounds  of  this  nature  the  pain  is  often  violent 
and  shock  is  very  severe. 

Treat77ient. — The    surgeon    endeavors    to    asepticize    the 


2l6  CONTUSIONS  AND    WOUNDS. 

wound  and  skin  about  it  (page  210),  arrests  hemorrhage,  and 
ligates  any  visible  damaged  vessel  whether  it  bleeds  or  not. 
Hopelessly  damaged  tissue  should  be  cut  away,  doubtful  tissue 
being  retained.  Secure  thorough  drainage,  in  some  situations 
making  counter-openings  if  necessary.  Tube-drainage  may  be 
necessary  or  iodoform-gauze  packing  may  be  used.  Con- 
tused wounds  and  lacerated  wounds  are  rarely  closed  by 
sutures  except  when  on  the  face.  They  are  rarely  closed  be- 
cause the  damage  is  so  great  and  the  blood-supply  so  inter- 
fered with  that  primary  union  will  not  occur.  In  the  face  the 
blood-supply  is  so  good  that  primary  union  may  be  obtained 
in  part  or  entirely,  and  it  is  worth  while  to  try  to  obtain  it. 
Dress  contused  and  lacerated  wounds  with  moist  antiseptic 
gauze  and  keep  the  part  at  rest.  Cold  must  not  be  applied 
to  a  region  of  lowered  vitality,  because  it  might  cause  gan- 
grene. Heat  is  useful.  Hence,  it  is  advisable,  even  from  the 
start,  to  dress  with  hot  antiseptic  fomentations,  and  this  mode 
of  dressing  becomes  imperative  if  sloughing  begins. 

If  suppuration  occurs,  the  surgeon  sees  to  it  that  the  pus  has 
free  exit,  and  if  necessary  secures  free  exit  by  making  incisions. 

Punctured  Wounds. — Punctured  wounds  are  made  with 
pointed  instruments,  as  needles,  pointed  knives,  pointed 
swords,  bayonets,  splinters,  etc.  An  arrow  wound  is  punct- 
ured and  incised.  The  depth  of  a  punctured  wound  greatly 
exceeds  its  surface  area.  After  the  withdrawal  of  the  instru- 
ment inflicting  the  injury  the  wound  partly  closes  at  points, 
blood  and  wound-fluid  cannot  find  exit,  and  if,  as  is  prob- 
ably the  case,  bacteria  were  deposited  in  the  tissues,  infec- 
tion with  pus  organisms  is  very  likely  to  occur,  and  if  it  does 
occur  suppuration  spreads  widely.  There  is  also  danger  of 
infection  with  tetanus  bacilli.  Such  a  wound  may  involve  an 
important  blood- vessel,  and  in  such  a  case  profuse  hemorrhage 
will  occur,  otherwise  hemorrhage  is  slight.  A  great  cavity  of 
the  body  may  be  penetrated  or  an  important  organ  may  be 
wounded.  Large-sized  foreign  bodies  may  be  driven  into  the 
tissues  or  a  portion  of  the  instrument  may  break  off  and 
lodo-e.  Pain  is  rarely  severe  unless  a  considerable  nerve 
has'' been  damaged.  If  both  a  large  vein  and  artery  are 
punctured,  varicose  aneurysm  or  aneurysmal  varix  may  arise. 

Treatment. — If  there  is  severe  hemorrhage,  enlarge  the 
wound  and  tie  the  bleeding  vessels.  In  a  puncture  not  made 
by  the  surgeon,  the  wound  must  be  regarded  as  infected.  It 
is  proper  that  the  skin  about  it  be  sterilized,  that  foreign 
bodies  be  removed,  that  the  wound  be  irrigated  with  an 
antiseptic  solution,  and  be  drained  with  a  tube  or  a  strip  of 


G  UNSHO  T-  WO  UNDS.  2  1 7 

gauze.  Such  treatment  though  painful,  and  appearing  un- 
necessarily severe  or  e\'en  cruel  to  the  sufferer  from  a  trivial 
puncture,  is  necessaiy,  and  may  save  the  patient  from  serious 
illness  or  from  death. 

Pure  carbolic  acid  is  one  of  the  most  efficient  of  agents 
to  sterilize  a  punctured  wound. 

If  an  important  cavity  of  the  body  has  been  invaded  by  a 
puncture,  exploratory  incision  is  necessary  (see  Brain,  Thorax, 
Abdomen).  An  arrow  should  not  be  pulled  out,  but  it 
should  be  pushed  through ;  or  if  its  situation  renders  such 
a  procedure  improper,  it  must  be  cut  down  upon  and 
withdrawn. 

Gunshot-wounds, — Gunshot-wounds  are  contused  or 
contused-lacerated  wounds  inflicted  by  materials  projected 
by  explosives.  A  bit  of  rock  or  a  crowbar  hurled  by 
dynamite  inflicts  a  gunshot-wound,  as  does  a  shell-fragment, 
a  pistol-ball,  a  small  birdshot,  a  rifle-bullet,  a  flying  cap,  a 
piece  of  wadding,  grains  of  powder,  a  buckshot,  a  fragment 
of  metal  broken  off"  a  shell,  grapeshot  and  canister,  or  a 
cannon-ball.  Injuries  by  shell-fragments,  portions  of  a 
bursted  boiler,  pieces  of  masonry  or  wood,  are  either 
lacerated  or  punctured  wounds,  and  need  no  special  consid- 
eration here.  In  this  article  we  treat  of  injuries  caused  by 
bullets  and  shot. 

The  round  bullet  of  the  old-time  musket  being  large,  mov- 
ing with  comparative  slowness,  and  flattening  easily,  is  very 
apt  to  lodge.  When  it  is  fired  from  close  range  and  strikes 
the  tissue  at  a  right  angle  it  produces  a  "  punched-out"  en- 
trance-wound. If  the  velocity  is  low  or  the  impact  is  not  at 
a  right  angle  to  the  tissues,  the  entrance-wound  may  "  be 
formed  of  triangular  flaps,"  the  corners  of  which  are  inverted.^ 
The  entrance-wound  is  surrounded  by  a  bruised  area.  The 
track  of  the  bullet  is  larger  than  the  bullet,  is  so  badly  con- 
tused and  lacerated  that  much  tissue  is  devitalized,  and  the 
shaft  of  a  bone  is  apt  to  be  splintered  if  struck.  If  the  ball 
emerges,  the  wound  of  exit  is  larger  than  the  bullet  and 
forms  triangular  and  everted  flaps  (Stevenson).  Healing  by 
first  intention  will  rarely  occur. 

The  conical  or  cylindrico-conoidal  rifle-bullet  has  much 
greater  velocity  and  penetrating  power  than  the  round  bullet, 
hence  it  is  more  apt  to  perforate.  The  track  of  this 
bullet  is  less  devitalized  than  is  the  track  of  the  round  ball 
and  the  surface  is  not  so  much  contused.  The  wound  of 
entrance  is  smaller  than  the  bullet  and  is  punched  out  or  in- 
1  Wounds  in  War,  by  Surg. -Colonel  W.  F.  Stevenson. 


2l8  CONTUSIONS  AND    WOUNDS. 

verted.  The  wound  of  exit  is  larger  than  that  of  entrance, 
and  is  often  everted.  The  bones  are  more  seriously  commi- 
nuted than  by  the  round  ball,  and  the  fragments  may  be  driven 
widely  into  the  tissues  (Stevenson) ;  in  fact,  an  explosive 
effect  may  occur  at  close  range.  Delorme  lays  it  down  as  a 
rule  that  comminution  of  bone  makes  the  wound  of  exit 
larger,  and  he  asserts  that  a  wound  of  exit  larger  in  diameter 
than  the  thumb  means  that  there  is  comminution  of  bone. 

At  the  present  day  the  old  round  ball  is  very  rarely  used, 
the  conical  projectile  having  taken  its  place.  For  the  fire- 
arms of  civilians,  as  a  rule,  the  bullets  are  made  of  lead,  hard- 
ened and  shaped  by  compression,  or  hardened  by  an  admixt- 
ure with  tin.  The  conical  shape  of  the  pistol-ball,  the  great 
velocity  with  which  it  is  propelled  and  with  which  it  rotates, 
and  its  hardness  make  it  unlikely  that  at  near  range  the 
bullet  will  only  contuse  and  not  enter  the  skin.  It  will  almost 
always  enter;  it  will  often  lodge  and  will  not  unusually  per- 
forate ;  it  is  rarely  deflected,  and  is  not  nearly  so  much  flat- 
tened by  impact  as  is  the  softer  round  ball.  A  pistol-ball  or  a 
spent  rifle-ball,  however,  may  fail  to  enter  the  tissues,  grazing 
the  surface  and  inflicting  a  brush-burn,  or  simply  contusing 
the  part.  A  bullet  may  enter  the  tissues,  a  ca\it}-,  or  an  organ, 
and  lodge  there,  causing  a  penetrating  wound.  It  ma}'  enter 
and  emerge,  causing  a  perforating  wound.  The  bullet  may 
not  enter  alone,  but  may  carry  with  it  bits  of  clothing  or 
other  foreign  bodies.  This  complication  is  much  more  rare 
in  injury  by  the  conical  bullet  than  by  the  round  ball. 

The  military  surgeon  deals  with  wounds  inflicted  by  small, 
densely  hard,  conical  projectiles,  which  are  impelled  at  a 
great  velocity  and  are  carried  to  long  distances.  A  rifle 
whose  caliber  is  less  than  0.35  inch  is  known  as  a  small- 
caliber  rifle.  The  best-known  modern  rifles  are  the  Lee- 
Metford,  Krag-Jorgensen,  Mauser,  Mannlicher,  Lebel,  and 
Schmidt-Rubin.  The  old  Springfield  rifle,  of  a  caliber  of 
0.45  inch,  projected  a  bullet  with  a  velocity  of  thirteen  hun- 
dred feet  in  a  second. 

The  Mannlicher  rifle,  of  a  caliber  of  0.25  to  0.32  inch, 
sends  a  bullet  with  a  velocity  of  over  two  thousand  feet  a 
second.  This  bullet  revolves  with  great  velocity  upon  its 
own  axis  (two  thousand  times  the  first  second)  and  is  effec- 
tive at  several  miles. 

The  bullet  of  the  modern  rifle  is  conical,  has  a  leaden  core, 
and  is  hardened  by  being  covered  with  a  mantle  or  jacket  of 
copper,  steel,  nickel,  or  of  alloys  of  copper  and  nickel,  or  of 
copper,  nickel,  and  zinc.     The  hard   jacket  is  absolutely  es- 


GUNSIIO  T-  IVOrXDS. 


219 


sential  because  the  speed  of  the  projectile  is  so  great  that  no  soft 
bullet  could  succeed  in  taking  the  rifling,  fragments  would 
be  torn  from  it  in  the  gun,  and  the  grooves  of  the  barrel 
would  soon  fill  up  with  metal,  the  gun  becoming  useless. 

The  Lee-Metford  bullet  is  elongated  in  outhne,  has  a 
core  of  lead  hardened  with  antimon}-,  and  the  envelope  is 
composed  of  an  alloy  of  nickel  and  copper. 

The  older  projectile  was  apt  to  lodge  ;  was  often  deflected 
in  the  tissues ;  was  flattened  out  on  meeting  with  resistant 
structures,  such  as  bone  or  cartilage,  and  after  flattening  be- 
came larger  and  tore  and  lacerated  the  soft  parts  and  com- 
minuted the  bone. 

The  new  projectile  is  apt  to  perforate,  is  rarely  deflected, 
and  is  so  hard  that  its  shape  is  generally  but  little  altered 


Fig.  64. — I,  End  view  of  2,  the  Krag-Jorgensen  bullet;   3,  Mauser  bullet; 
bullet,  used  by  the  U.  S.  Navy. 


4,  Lee-Metford 


on  meeting  with  resistant  structures,  and  hence  it  was 
thought  that  the  new  bullet  would  prove  more  humane  than 
the  old  projectile,  and  inflict  wounds  which  would  be  more 
easily  treated,  because  the  bullets  would  not  lodge  and 
because  extensive  damage  would  not  be  inflicted.  This  view 
has  proved  to  a  great  extent  correct.  In  many  instances  a 
modern  bullet  will  make  a  clear  track  without  laceration 
or  comminution.  Senn,  Nancrede,  and  other  American  sur- 
geons in  the  Spanish-American  War  say  the  modern  pro- 
jectile is  humane  at  a  range  over  fifteen  hundred  yards,  as 
it  generally  penetrates  cleanly,  making  a  wound  which  heals 
often  by  first  intention.  Mr.  Treves  says  "  the  Mauser  bullet 
is  a  ver}^  merciful  one."  In  some  instances,  however,  the 
small  bullet  pulpefies  structure  for  a  considerable  distance 
around  the  track  of  the  ball  by  what  is  known  as  the  ex- 
plosive effect.     This   term  does  not  mean  that  the  bullet  has 


220  CONTUSIONS  AND    WOUNDS. 

exploded,  but  that  its  sudden  impact  against  tissues  has  by 
waves  of  force  caused  extensive  and  distant  damage,  and 
often  horrible  and  irreparable  injur}'.  Explosive  effects  are 
seen  most  often  at  close  range,  when  the  velocity  of  the  ball 
and  the  frequency  of  its  rotation  are  most  marked.  A  pistol- 
ball  has  no  explosive  action  at  all,  and  the  old-time  bullet 
possessed  it  only  at  very  close  range.  The  modern  projec- 
tile always  produces  explosive  effects  up  to  five  hundred 
yards.  Up  to  thirteen  hundred  yards  it  produces  them  upon 
the  skull  and  brain.  At  this  distance  a  single  small  projectile 
may  entirely  destroy  the  cranium  and  brain  (see  Demosthen's 
studies  of  the  action  of  the  Mannlicher  rifle).  Explosive 
effects  are  noted  at  longer  distances  upon  the  liver,  spleen, 
kidney,  and  lungs,  and  upon  hollow  viscera  containing  fluid. 

At  a  distance  of  five  hundred  yards  or  less  a  bone  will  be 
shattered  into  many  fragments.  At  a  range  of  fifteen  hun- 
dred or  two  thousand  yards  the  bone  will  be  cleanly  per- 
forated, usually  without  comminution.  It  is  often  extra- 
ordinary how  little  trouble  follows  a  wound  and  how  quickly 
healing  occurs.  This  is  due  to  the  fact  that  the  bullet  is 
sterile  when  it  reaches  the  tissue,  and  that  foreign  bodies  are 
rarely  carried  in  with  it.  In  some  observed  cases  there  have 
been  almost  no  symptoms  after  perforation  of  the  lungs,  in 
others  after  perforation  of  the  abdomen  or  joints  or  skull. 
It  is  obvious  that  the  humanity  of  the  modern  rifle  is  largely 
a  matter  of  range.  At  a  range  of  fifteen  hundred  yards  or 
more  it  is  a  humane  weapon. 

The  wound  of  entrance  is  extremely  small,  and  could  be 
overlooked  by  a  careless  observer.  It  is  usually  circular,  but 
may  be  triangular.  The  wound  of  exit  is  also  small,  and  may 
be  round  or  may  be  a  slit.  If  the  injury  was  inflicted  at  close 
range,  the  wound  of  exit  is  large.  This  projectile  theoretically 
does  not  flatten,  but  practically  in  many  instances  it  does  flat- 
ten a  little,  and  in  others  its  coat  is  torn  off  when  it  strikes 
hard  bone  at  a  distance  of  less  than  eighteen  hundred 
yards.  Treves  points  out  that  if  the  bullet  smashes  a  bone 
and  lodges,  the  shell  peels  off  from  the  core  as  a  rule,  and 
the  bullet  may  be  distorted  or  even  broken  into  fragments. 
The  bullet  may  lodge  at  long  range,  or  if  it  hits  a  man  after 
bounding  from  a  stone.  In  Cuba  lo  per  cent,  of  the  wounded 
suffered  from  lodged  bullets.  The  old-style  bullet  rarely 
caused  much  primary  hemorrhage,  as  the  vessels  as  well  as 
the  nerves  and  tendons  were  usually  pushed  aside  rather 
than  cut.  Hence  secondary  hemorrhage  was  common 
because  of  contusion  of  the  vessel-walls.     The  modern  bul- 


GCXSHOT-irOCXDS.  221 

let  cuts  rather  than  pushes  aside  the  vessels.  Hence 
primar}'  hemorrhage  is  profuse  if  a  large  vessel  is  struck, 
and  may  prove  fatal.  The  modern  bullet  rarely  lodges 
and  is  rarely  deflected.  Skin  is  usually  split  by  it.  Fascia 
and  muscle  are  usually  much  damaged,  but  in  a  transverse 
wound  of  muscle  the  fibers  may  be  separated  rather  than  be 
destroyed  [  Conner).  The  eftects  of  the  modem  bullet  ha\-e 
been  determined  by  careful  study  and  experiment ;  by  a  study 
of  the  wounds  in  the  Chitral  Expedition  and  of  wounds  in- 
flicted by  accident  or  with  homicidal  or  suicidal  intent ;  by 
experiments  :  firing  through  boxes  filled  with  wet  sand  ;  fir- 
ino-  into  thick  oak ;  firing  at  cadavers  at  fixed  distances  with 
reduced  charges  (La  Garde' :  firing  at  corpses  and  at  li\-e 
horses  with  sen'ice-charges  (  Demosthen ).  Xancrede  cautions 
us  to  remember  that  experiments  upon  the  cadaver,  emplo\-- 
ing  reduced  charges  and  standing  at  fixed  distances,  are  un- 
certain in  their  provings.  "  The  difference  between  the  veloc- 
ity  of  rotation  and  angle  of  incidence  with  reduced  charges 
at  fixed  distances  and  senice-charges  at  actual  distances  are 
marked.  The  tension  of  living  muscles  and  fasciae,  as  com- 
pared with  dead  tissues,  and  the  physical  change  of  the  semi- 
liquid  fat  of  adipose  tissue  and  medulla  to  a  more  solid  con- 
dition by  the  loss  of  animal  heat,  influence  the  results."  ^ 

All  theoretical  conclusions  have  been  put  to  the  test  in 
the  Spanish-American  War  and  the  South  African  War,  and 
preconceived  opinions  have  to  a  great  extent  been  confirmed. 
The  effect  of  the  bullet  at  close  range  was  obsen-ed  in  the 
marines  killed  at  Guantanamo.  in  persons  killed  during  the 
Milan  riots,  and  in  many  instances  in  South  Africa. 

It  has  been  found  that  the  modem  small-caliber  bullet. 
unless  it  strikes  a  vital  part  or  a  large  bone,  lacks  "  stopping 
power,"  and  in  warfare  with  savages  the  bullet  must  ha\-e 
stopping  power,  or  the  wounded  man  will  continue  to  fight 
and  charge.  CiviHzed  men  will  usualh'  stop  when  hit,  sav- 
ages often  will  not ;  hence,  in  warfare  with  barbarous  people 
the  ordinar}-  bullet  must  be  modified.  In  the  Dumduni  bul- 
let a  portion  of  lead  at  the  apex  of  the  projectile  is  left  un- 
covered, and  the  bullet  when  it  strikes  spreads  out — mush- 
rooms, as  it  is  called — and  inflicts  an  extensive  wound  which 
*'  stops  "  the  most  ferocious  and  fanatical.     German  surgeons 

1  Nancrede  upon  "  Gunshot  Wounds,"'  in  Park's  Surgery  by  American  Authors. 
For  information  upon  wounds  by  the  modem  firearm,  see  report  of  Surgeon- 
General  of  the  United  States  Army.  1893.  Demosthen"s  study  of  the  wounds 
inflicted  by  the  Mannlicher  rifle,  Prof.  Conner,  in  Dennis's  System  of  Surgery, 
and  Forw'ood,  in  The  International  Text-Book  of  Surgery. 


222  CONTUSIONS  AND    WOUNDS. 

denounce  such  bullets  as  inhumane,  but  Stevenson  and  other 
English  surgeons  say  that  the  Dumdum  bullet  is  more  hu- 
mane than  the  Snider  or  Martini-Henry.  The  name  Dum- 
dum comes  from  the  ordnance  factory,  near  Calcutta,  where 
bullets  of  this  character  were  first  made. 

"Wounds  by  Cannon-balls. — A  cannon-ball  weighing  five 
or  six  pounds  may  be  imbedded  in  tissues.  A  ball  or  shell- 
fragments  may  tear  off  a  limb  or  lacerate  it  extensively.  In 
some  cases  of  injury  by  spent  balls  the  bone  is  destroyed  and 
the  muscles  disorganized  while  the  skin  is  intact. 

"Wounds  by  Small  Shot. — Single  shot  may  bruise  the 
surface  or  may  enter  the  tissues.  When  many  shot  enter 
together  they  strike  as  a  solid  body.  Single  shot  are  usually 
deflected  from  vessels  and  nerves,  and  rarely  lodge  in  bone, 
but  rather  flatten  on  its  surface.  Numerous  shot  entering 
together  produce  extensive  laceration  and  inflict  damage 
which  is  often  irreparable. 

Symptoms  of  a  Gunshot-wound. — Hemorrhage  is  often 
considerable,  but  ceases  spontaneously  unless  a  large  vessel 
has  been  divided.  If  hemorrhage  is  profuse,  the  constitu- 
tional symptoms  of  hemorrhage  exist.  These  symptoms  are 
of  great  importance  in  abdominal  wounds.  A  pistol-ball 
rarely  causes  severe  primary  hemorrhage,  because  it  will  not 
often  penetrate  a  large  artery.  It  is  apt  to  push  aside  a 
vessel,  and  secondary  hemorrhage  is  not  unusual.  Even  if  a 
large  vessel  is  wounded  and  a  succession  of  violent  hemor- 
rhages occur,  a  man  may  live  for  several  days.  Secondary 
hemorrhage  may  follow  a  gunshot-wound  because  of  con- 
tusion of  vessels  or  of  infection. 

Pain  is  often  not  noticed  at  first,  especially  if  the  injured 
individual  were  greatly  preoccupied  or  excited.  There  may 
be  a  feeling  of  numbness,  but  there  is  usually  a  dull  or  sting- 
ing pain.  If  a  large  nerve  is  injured,  there  may  be  violent 
pain.  Even  trivial  gunshot-wounds  frequently  produce  pro- 
found shock,  and  yet  it  may  happen  that  even  severe  wounds 
may  be  accompanied  by  but  slight  shock.  In  most  gunshot- 
wounds  of  the  brain,  abdomen,  and  spinal  cord  the  shock  is 
very  great. 

General  Considerations  as  to  Treatment. — The  dangers 
are  shock,  hemorrhage,  and  infection.  Bullets  are  aseptic 
when  they  enter  a  part,  and  if  infection  is  not  inserted  in  the 
track  of  the  ball  the  wound  will  in  most  instances  heal  kindly. 
"  The  fate  of  a  wounded  man  is  in  the  hands  of  the  surgeon 
who  first  attends  him"  (Nussbaum).  The  danger  of  a 
wound  depends  upon  the  size  and  velocity  of  the  bullet,  the 


G  UXSHO  T-irO  L'XDS. 


223 


part  struck,  "  and  the  degree  of  asepsis  observed  during  the 
first  examination  and  dressing  "  (Nancrede).  The  rules  of 
treatment  are  :  bring  about  reaction,  arrest  hemorrhage,  pre- 
ser\-e  asepsis,  and,  in  some  cases,  remove  the  ball.  Always 
notice  if  a  wound  of  exit  exists.  It  is  a  good  plan,  when 
endeavoring  to  determine  the  extent  of  injuiy,  to  put  the 
parts  in  the  position  they  w^ere  in  when  the  injury  was  inflicted. 
We  should  try  to  ascertain  the  size  and  nature  of  the  weapon, 
and  the  range  at  which  it  was  fired.  Examine  the  clothing 
to  see  if  any  fragments  are  missing  and  could  ha\-e  been  car- 
ried in.  Such  fragments  render  sepsis  almost  ine\itable. 
The  surgeon  must  not  feel  it  his  duty  to  probe  in  all  cases. 
In  many  cases  it  is  better  not  to  probe  at  all.  Explore  for 
the  ball  when  sure  that  it  has  carried  with  it  foreign  bodies  ; 
when  its  presence  at  the  point  of  lodgement  interferes  with 
repair  ;  when  it  is  in  or  near  a  \-ital  region  (as  the  brain) ;  and 
when  it  is  necessaiy  to  know  the  position  of  the  bullet  in 
order  to  determine  the  question  of  amputation  or  resection. 
If  the  wound  is  large  enough,  the  finger  is  the  best  probe. 

Fluhrer's  aluminum  probe  is  a  valuable  instrument.  It  is 
employed  especially  in  brain-wounds,  and  is  allowed  to  sink 
into  the  track  of  the  ball  by  the  influence  of  gravit}'  after  the 
part  has  been  placed  in  a  proper  position.  If  a  lead  bullet  is 
deeply  imbedded,  it  is  possible  to  distinguish .  the  hard  pro- 
jectile from  a  bone  by  inserting  the  asepticized  stem  of  a 
clay  pipe,  a  bit  of  pine  wood,  or  Nelaton's  porcelain-headed 
probe.  On  any  one  of  these  appliances  lead  will  make  a 
black  mark.  No  such  test  can  be  applied  to  a  modern  bullet, 
for  this  has  a  hard  metal  jacket,  and  will  not  make  a  black 
mark  on  a  white  substance. 

Though  Nelaton's  probe  will  not  show  the  difference  be- 
tween a  hard  projectile  and  bone,  it  is  a  valuable  instrument 
to  follow  the  track  of  a  wound.  The  porcelain  head  ought 
to  be  larger  than  it  is  usually  made — in  fact,  it  should  be 
nearly  the  size  of  the  bullet  (Sennl 

In  passing  a  probe  use  no  more  force  than  in  passing  a 
catheter  (Senn). 

The  induction-balance  of  Graham  Bell  has  been  employed 
to  determine  the  situation  of  a  bullet.  The  bullet  ma}-  be 
located  by  Girdncrs  tclepJuvnc  probe.  In  order  to  construct 
this  instrument,  take  a  telephone  receiver,  fasten  one  of  the 
wires  to  a  metal  plate  and  the  other  one  to  a  metallic  probe. 
Moisten  a  portion  of  the  patient's  body  and  place  the  metal 
plate  in  contact  with  it.  The  surgeon  places  the  receiver  to 
his  ear  and  inserts   the  probe  into  the  wound.     If  the  probe 


224 


CONTUSIONS  AND    WOUNDS. 


strikes  metal,  a  click  is  heard  with  distinctness.  A  bullet 
may  be  located  by  Liliejithar s  probe.  This  apparatus  con- 
sists of  a  mouth-piece,  two  insulated  copper  wires,  and  a 
probe.  The  mouth-piece  is  composed  of  two  plates,  one  of 
copper  and  one  of  zinc,  which  are  applied  to  the  sides  of  the 
tongue.  An  insulated  wire  runs  from  each  plate  and  into  the 
metal  probe.  The  tip  of  the  probe  is  composed  of  two  or 
four  pieces  of  metal,  is  separated  from  the  shank  by  a  washer 
of  rubber,  and  is  attached  to  the  wires.  The  operator  closes 
the  teeth  upon  the  mouth-piece,  and  inserts  the  probe  into  the 
wound.  If  the  probe  touches  the  bullet,  a  distinct  and  con- 
tinuous metallic  taste  is  appreciable. 

The  best  means  of  discovering  a  bullet  is  to  use  the  fluoro- 
scope  or  take  a  skiagraph.  In  order  to  locate  it  accurately, 
view  it  through  a  series  of  squares,  insert  guide-pins,  or 
employ  Sweet's  apparatus.  Bullets  are  readily  seen  by  the 
fluoroscope  in  the  superficial  soft  parts,  and  are  discovered 
in  deeper  structures  (bone,  abdomen,  lung,  brain,  etc.)  by 
taking  skiagraphs. 

In  extracting  the  ball  use  very  strong  forceps  (Fig.  64). 
The  old  American  bullet-forceps  is  useless  for  the  extraction 


Fig.  65. — Bullet-forceps. 


of  the  hard-jacketed  ball,  as  the  points  of  the  instrument  will 
not  penetrate  and  the  instrument  will  not  hold. 

If  hemorrhage  is  severe  in  a  gunshot-wound,  enlarge  the 
wound,  find  the  bleeding  vessel,  and  tie  it.  Before  handling 
a  gunshot-wound  asepticize  the  parts  about  it  and  irrigate  the 
wound  with  hot  sterile  salt  solution.  In  some  situations  a 
wound  should  be  drained  with  a  short  tube  or  a  bit  of  iodo- 
form gauze;  in  other  regions  this  is  unnecessary.  The  dress- 
ing should  be  antiseptic.  Primary  union  rarely  takes  place 
after  a  wound  inflicted  by  a  pistol-ball  or  an  ordinary  rifle- 
ball,  because  of  the  inevitable  necrosis  of  damaged  tissue  in 
the  track  of  the  ball,  but  in  some  cases  it  can  be  obtained. 
Primary  union  is  frequent  after  injury  by  the  small  hard- 
jacketed  modern  projectile.  Healing  begins  in  the  depths 
of  the  wound  and  extends  toward  the  wound  of  entrance,  or. 


POISONED  irorxDS.  225 

if  there  be  also  a  wound  of  exit,  toward  both.  Radical  opera- 
tions may  be  demanded  :  laparotom)-,  trephining,  rib-resec- 
tion, joint-resection,  and  amputation. 

Amputation  is  sometimes  demanded  because  of  great 
injury  to  the  soft  parts  (as  b}-  a  shell-fragment),  the  splinter- 
ing of  a  bone,  injur\'  of  a  joint,  damage  to  the  chief  vessels 
or  ner\^es,  or  the  destruction  of  a  considerable  part  of  a  limb. 
Perform  a  primaiy  amputation  if  possible,  and  make  the  flaps 
through  tissue  that  will  not  slough.  In  civil  practice,  with 
careful  antisepsis,  more  questionable  tissue  can  be  admitted 
into  a  flap  than  in  militar}-  practice,  where  transportation  will 
become  necessar}'  and  antisepsis  may  be  imperfect  or 
wanting. 

Prevention  of  infection  in  zvonnds  i)ijficted  in  zvar  is  of 
great  importance.  In  warfare  at  the  present  da}'  an  attempt 
is  made  to  limit  the  death-rate  from  gunshot-wounds  b}-  pro- 
tecting them  from  infection  at  an  early  period  after  the  acci- 
dent. Esmarch  offered  a  suggestion,  Avhich  has  been  adopted 
in  the  armies  of  all  civilized  countries.  Ever}-  soldier  car- 
ries a  package  which  contains  antiseptic  dressings,  and  at  the 
first  opportunity  after  the  infliction  of  a  wound,  if  possible  on 
the  field,  these  dressings  are  applied  b}-  the  soldier  or  b}-  a 
comrade  (for  even  the  privates  are  instructed  in  the  applica- 
tion), or  by  an  ambulance-man.  If  not  applied  on  the  field, 
they  are  applied  at  the  first  dressing-station  b}-  a  surgeon  or 
a  hospital  steward.  Senn  considers  Esmarch "s  package  too 
cumbrous.^  He  suggests  a  package  containing  half  an  ounce 
of  compressed  salicylated  cotton.  In  the  center  of  this  cot- 
ton is  an  antiseptic  powder  (2  gm.  of  boric  acid  and  \  gm.  of 
salic}-lic  acid).  The  cotton  is  wrapped  in  a  triangular  gauze 
bandage.  A  safety-pin  is  placed  in  the  bandage  and  the  en- 
tire bundle  is  wrapped  in  gutta-percha  tissue.  Senn  sa}'s  the 
triangular  bandage  is  sufficient  to  hold  a  dressing  in  place,  and 
it  can  be  assisted  by  utilizing  the  gunstrap,  safety-belt,  or 
articles  of  clothing.'  (For  gunshot-wounds  of  special  struc- 
tures, see  Bones,  Joints,  etc.) 

Poisoned  wounds  are  those  into  which  some  injurious 
substance,  chemical  or  bacterial,  was  introduced.  This 
poison  may  be  microbic  and  capable  of  self-multiplication,  or 
it  ma}^  be  chemical,  and  hence  incapable  of  multiplication. 
There  are  three  classes  of  poisons:^  (i)  mixed  infection,  as 
septic  wounds,  dissection-wounds,  and  malignant  edema  ;  (2) 

^  Jo7ir.  Am.  Med.  Assoc,  July  13,  1S95. 

2  Senn,  in  Joic?-.  Am.  Med.  Assoc,  July  13,  1895. 

'  American  Text-book  of  Surgery. 

15 


226  CONTUSIONS  AND    WOUNDS. 

chemical  poison,  such  as  snake-bites  and  insect-stings ;  and 
(3)  infection  with  such  diseases  as  rabies,  glanders,  etc. 

Septic  wounds  are  those  which  putrefy,  suppurate,  or 
slough.  Septic  wounds  should  be  opened  freely  to  secure 
drainage,  and  hopelessly  damaged  tissue  should  be  curetted  or 
cut  away.  The  wound  should  be  washed  with  peroxid  of 
hydrogen  and  then  with  corrosive  sublimate,  dusted  with 
iodoform  or  orthoform,  either  drained  with  a  tube  or  packed 
with  iodoform  gauze  and  dressed  with  hot  antiseptic  fomen- 
tations. The  part  must  be  kept  at  rest  and  internal  treatment 
should  be  stimulating  and  supporting.  If  lymphangitis 
arises,  the  skin  over  the  inflamed  vessels  and  glands  is  to 
be  painted  with  iodin  and  smeared  with  ichthyol,  and  quinin, 
iron,  and  whiskey  are  given  internally.  The  temperature  is 
watched  for  evidence  of  general  infection  or  intoxication. 
The  patient  must  be  stimulated  freely,  nourishing  food  is 
given  at  frequent  intervals,  pain  is  allayed  by  anodynes  if 
necessary,  and  sleep  is  secured. 

Dissection-wounds  are  simple  examples  of  infected 
wounds,  and  they  present  nothing  peculiar  except  virulence. 
They  affect  butchers,  cooks,  surgeons  who  cut  themselves 
while  operating  on  infected  areas,  those  v/ho  make  post-mor- 
tems, and  those  who  dissect.  A  dissection-wound  inflicted 
while  working  on  a  body  injected  with  chlorid  of  zinc  pos- 
sesses but  few  elements  of  danger  unless  the  health  of  the 
student  is  much  broken  down.  If  a  wound  is  simply 
poisoned  with  putrefactive  organisms,  there  is  rarely  serious 
trouble.  Post-mortems  are  pecuharly  dangerous  when  the 
subject  has  died  of  some  septic  process.  When  a  wound  is 
inflicted  while  dissecting,  wash  it  under  a  strong  stream  of 
water,  squeeze,  and  suck  it  to  make  the  blood  run,  lay  it 
open  if  it  be  a  puncture,  paint  it  with  pure  carbolic  acid, 
and  dress  it  with  iodoform  and  hot  antiseptic  fomentations. 
Trouble,  of  course,  may  follow,  but  often  it  is  only  local, 
and  a  small  abscess  forms.  It  should  be  treated  by  hot  anti- 
septic fomentations  and  early  incision.  Occasionally  lymph- 
angitis arises,  adjacent  glands  inflame,  and  constitutional 
symptoms  arise.  It  is  rarely  that  true  septicemia  or  pyemia 
arises  unless  the  wound  was  inflicted  while  making  a  post- 
mortem upon  a  person  dead  of  septicemia  or  while  oper- 
ating on  a  septic  focus.  If  glands  enlarge,  it  may  be  neces- 
sary to  remove  them  surgically. 

Malignant  edema  or  gangrenous  emphysema  arises 
most  commonly  after  a  puncture.  It  is  due  to  a  specific 
bacillus    which    produces    great   edema.     The    emphysema 


ST/A^GS  A. YD  BITES   OF  IXSECTS  AXD   REPTILES.      22/ 

which  soon  arises  is  due  to  mixed  infection  with  putrefactive 
organisms.  PusMoes  not  form,  but  o;an«;rene  occurs.  The 
disease  is  identical  with  one  form  of  traumatic  spreading  gan- 
grene (page  158). 

Emphysematous  gangrene  may  also  be  caused  by  the 
bacillus  aerogenes  capsulatus.  The  organisms  gain  access 
through  a  wound. 

Symptoms. — The  symptoms  are  identical  with  those  of 
traumatic  spreading  gangrene  with  emph}'sema. 

There  is  a  rapidly  spreading  edema,  followed  by  gaseous 
distention  of  the  tissues  and  by  gangrenous  cellulitis.  The 
zone  of  edema  is  at  the  margin  of  the  emphysema,  and  the 
process  spreads  rapidly.  The  emphysematous  zone  crackles 
when  pressed  upon.  The  area  of  edema  is  covered  with 
blebs  which  contain  thin,  putrid,  reddish  matter,  and  the  skin 
becomes  mottled.  If  a  w'ound  exists,  the  discharge  will  be 
bloody  and  foul.  If  incisions  are  made,  a  thin,  brown, 
offensive  liquid  flows  out.  High  fever  rapidly  develops, 
the  patient  becomes  delirious,  and  often  coma  arises.  In 
most  cases  death  ensues  in  from  twenty-four  to  forty-eight 
hours. 

Treatment. — If  malignant  edema  affects  a  limb,  ampu- 
tate at  once,  high  up.  If  it  affects  some  other  part,  make 
free  incisions,  emplo\'  hot,  continuous  antiseptic  irrigations  or 
the  hot  antiseptic  bath,  and  stimulate  freely. 

Stings  and  Bites  of  Insects  and  Reptiles  :  Stings 
of  Bees  and  Wasps. — A  bee's  sting  consists  of  two  long 
lances  within  a  sheath  with  which  a  poison-bag  is  connected. 
The  wound  is  made  first  by  the  sheath,  the  poison  then 
passes  in,  and  the  two  lances,  moving  up  and  down,  deepen 
the  cut.  The  barbs  on  the  lances  make  it  difficult  to  rapidly 
withdraw  the  sting,  which  may  be  broken  off  and  remain  in 
the  flesh.  Besides  bees,  hornets,  yellow  jackets,  and  other 
wasps  produce  painful  stings.  These  stings  rarely  cause 
any  trouble  except  pain  and  swelling.  In  some  unusual 
cases  a  bee-sting  is  fatal ;  persons  have  been  stung  to  death 
by  a  great  number  of  these  insects. 

Symptoms. — If  general  symptoms  ensue,  they  appear 
rapidly,  and  consist  of  great  prostration,  vomiting,  purging, 
and  deHrium  or  unconsciousness.  These  symptoms  may 
disappear  in  a  short  time,  or  they  may  end  in  death  from 
heart-failure.  Stings  of  the  mouth  may  cause  edema  of  the 
glottis. 

Treatment. — To  treat  a  bee-sting,  extract  the  sting  if  it 
be  broken  off,  and  apply  locally  ichth}'ol,  a  solution  of  wash- 


228  COiVTCrS/ONS  AND    WOUNDS. 

ing-soda,  ammonia-water,  tincture  of  arnica,  iodin,  or  lead- 
water  and  laudanum.  If  constitutional  symptoms  appear, 
stimulate. 

Other  Insect-bites  and  Stings. — The  mandibles  of  a 
poisonous  spider  are  terminated  by  a  movable  hook  which  has 
an  opening  for  the  emission  of  poison.  The  bite  of  large 
spiders  is  productive  of  inflammation,  swelling,  weakness, 
and  even  death.  The  bite  of  the  poisonous  spider  of  New 
Zealand  produces  a  large  white  swelling  and  great  prostra- 
tion ;  death  may  ensue,  or  the  victim  may  remain  in  a  de- 
pressed, enfeebled  state  for  weeks  or  even  for  months.  The 
tarantula  is  a  much-dreaded  spider.  A  scorpion  has  in  its 
tail  a  sting.  The  sting  of  a  scorpion  produces  great  prostra- 
tion, delirium,  vomiting,  diaphoresis,  vertigo,  headache,  local 
swelling,  and  burning  pain,  followed  often  by  suppuration,  or 
even  by  gangrene  and  fever.  Centipedes  must  be  of  large 
size  to  be  formidable  to  man,  and  the  symptoms  arising  from 
their  stings  are  usually  only  local. 

Treatment. — Tie  a  fillet  above  the  bitten  point ;  make  a 
crucial  incision,  favor  bleeding,  and  paint  the  wound  with 
pure  carboHc  acid  or  some  caustic  or  antiseptic  (if  in  the 
wilds,  burn  with  fire  or  gunpowder) ;  dress  antiseptically  if 
possible,  and  stimulate  as  constitutional  symptoms  appear. 
Slowly  loosen  the  ligature  after  symptoms  disappear.  Chlo- 
roform stupes  and  ipecac  poultices  are  recommended ;  also 
puncture  with  a  needle  and  rubbing  in  a  mixture  of  3  parts 
of  alcohol  and  i  part  of  camphor  (Bauerjie). 

Snake-bites. — The  poisonous  snakes  of  America  com- 
prise the  copperheads,  water-moccasins,  rattlesnakes,  and 
vipers.  There  is  also  a  poisonous  lizard.  The  symptoms 
of  snake-bite  are  similar  whether  it  is  the  bite  of  an  Indian 
cobra  or  of  an  American  rattler,  and  they  depend  upon  the 
dose  of  poison  introduced.  Poison  injected  into  a  vein  may 
prove  almost  instantly  fatal.  The  poison  is  not  absorbed  by 
the  sound  mucous  membranes.  It  is  discharged  through 
the  hollow  fangs  of  the  reptile,  having  been  forced  out  by 
contractions  of  the  muscles  of  the  poison-bag.  In  most  va- 
rieties of  snakes  the  teeth  lie  along  the  back  of  the  mouth 
and  are  only  erected  when  the  reptile  strikes.  The  poison 
contains  proteid  constituents,  globulins,  and  peptones 
(Mitchell  and  Reichert),  and  probably  toxic  animal  alkaloids 
(Brieger).  S.  Weir  Mitchell  has  shown  that  rattlesnake 
venom  exerts  a  paralyzing  action  upon  the  walls  of  the 
smaller  blood-vessels,  converts  the  blood,  into  a  non-coagu- 
lable  fluid,  causes  the  white  blood-cells  and  the  fluid  elements 


SXAA'E- BITES.  229 

of  blood  to  extravasate  into  the  tissues,  and  disintegrates  the 
red  corpuscles. 

Symptoms. — The  symptoms  are — pain,  soon  becoming 
intense ;  mottled  swelling  of  the  bitten  part,  which  swelling 
may  be  enormous,  and  which  is  due  to  edema  and  extrava- 
sation of  blood,  and  assumes  a  pui-puric  discoloration. 
There  may  be  complete  consciousness,  or  there  may  be 
letharg}-,  stupor,  or  coma.  Some  cases  present  spasms. 
The  general  symptoms  are  those  of  profound  shock,  which 
may  present  delirium  (delirious  shock).  Death  may  arise 
from  paralysis  of  the  heart  or  parah-sis  of  respiration,  and 
may  occur  in  about  five  hours,  but  as  a  rule  it  is  postponed 
for  a  number  of  hours.  If  death  is  deferred  many  hours, 
profound  sepsis  comes  upon  the  scene,  with  glandular  en- 
largement, suppuration,  and  sometimes  gangrene. 

Treatment. — Cases  of  snake-bite  must,  as  a  rule,  be 
treated  without  proper  appliances.  The  elder  Gross  was  ac- 
customed to  relate  in  his  lectures  how  he  had  seen  an  army 
officer  blow  off  his  finger  with  a  pistol  the  moment  it  was 
struck,  and  thus  escape  poisoning.  In  general,  the  rules  are 
to  twist  se^"eral  fillets  at  different  levels  above  the  bite,  to  ex- 
cise the  bitten  area,  to  suck  or  cup  it  if  possible,  and  to  cau- 
terize it  \\'ith  a  pure  acid  or  by  heat.  An  expedient  among 
hunters  is  to  cauterize  b}'  pouring  gunpowder  on  the  ex- 
cised area  and  apphing  a  spark,  or  b\'  la}4ng  a  hot  ember  on 
the  wound.  Wlien  a  hot  iron  is  available,  use  it.  The  fillets 
are  not  to  be  removed  suddenly,  and  the}'  had  best  be  kept 
on  for  some  time.  Remove  the  highest  constricting  band 
first ;  if  no  symptoms  come  on  after  a  time,  remove  the  next, 
and  so  on ;  if  s}^mptoms  appear,  reapply  the  fillet.  The 
constitutional  treatment  is  expressed  in  one  word  :  stimulate. 
Our  only  hope  is  in  large  doses  of  alcohol,  and,  if  they  can 
be  obtained,  ammonia,  ether,  stiychnin,  or  digitalis  hypoder- 
matically  administered.  Large  doses  of  strychnin  hypoder- 
matically  are  used  by  many  surgeons  in  India.  Morphin  may 
be  required  for  pain.  There  is  no  specific  for  snake-poison. 
Hypodermatic  injections  of  a  i  per  cent,  solution  of  the  per- 
manganate of  potassium  in  the  area  adjacent  to  the  bite  are 
commended  by  some.  The  local  use  of  chlorid  of  lime  has 
recently  been  recommended.  Halford  of  Australia  praises 
the  intravenous  injection  of  ammonia  (loTTl  of  strong  am- 
monia in  20TIX  of  water).  If  a  man  is  bitten  b\'  a  large  and 
deadly  snake,  the  surgeon,  if  one  is  at  hand,  should  at  once 
amputate  well  abt)ve  the  bite.^     Attempts  are  being  made  to 

^  Charters  James  Symonds,  in  Heath' s  Dictionary  of  Practical  Surgery. 


230  CONTUSIOA'S  AND    WOUNDS. 

obtain  a  curative  serum.  Animals  can  be  rendered  immune 
by  giving  them  at  first  small  doses  of  the  poison  and  gradu- 
ally increasing  the  amount  administered.  It  is  asserted  that 
the  serum  of  immune  animals  will  cure  a  person  bitten  by  a 
venomous  snake.  Cures  have  been  reported  after  the  use  of 
Calmette's  antivenene  serum.  The  dose  is  20  c.c.  hypoder- 
matically,  repeated  if  necessary  in  three  or  four  hours.  Al- 
exander ^  treated  a  case  successfully  by  making  an  incision 
into  the  bitten  area,  pouring  into  the  wound  rattlesnake  bile, 
and  giving  carbonate  of  ammonium  internally.  The  poison- 
ous lizard  (Gila  monster)  can  kill  small  animals,  but  it  is  not 
believed  that  its  bite  would  prove  fatal  to  man. 

Anthrax  (malignant  pustule,  charbon,  wool-sorters'  dis- 
ease. Milzbrand,  or  splenic  fever)  is  a  term  used  by  some  as 
synonymous  with  ordinary  carbuncle,  but  it  is  not  here  so 
employed.  Anthrax,  as  met  with  in  man,  is  a  disease  con- 
tracted in  some  manner  from  an  animal  with  splenic  fever. 
It  may  be  contracted  by  working  around  diseased  animals, 
by  handling  or  tanning  their  hides,  by  sorting  their  hair  or 
wool ;  it  may  be  conveyed  by  eating  infected  meat  or  by 
drinking  infected  milk.  Flies  may  carry  the  poison.  Inha- 
lation of  poisoned  dust  may  infect  the  lungs.  Catgut  liga- 
tures may  be  contaminated  and  carry  the  poison.  Many  at- 
tempts, not  altogether  satisfactory,  have  been  made  to  render 
animals  immune  (Pasteur,  Woolbridge,  Hankin).  Certain 
organisms  are  antagonistic  to  anthrax  (the  streptococcus  of 
erysipelas,  the  pneumococcus,  the  micrococcus  prodigiosus, 
and  the  bacillus  pyocyaneus). 

Forms  of  Anthrax. — There  are  two  forms  of  the  disease 
— external  and  internal.  Internal  anthrax  may  be  intestinal 
from  eating  diseased  meat  or  pulmonary  from  inhalation  of 
poisoned  dust.  External  anthrax  may  be  anthrax  carbuncle 
or  anthrax  edema.  The  exte^nial  form  appears  in  from  thi'ee 
to  six  days  after  inoculation,  and  presents  a  papule  with  a  red 
base ;  the  papule  becomes  a  vesicle  which  contains  bloody 
serum  ;  the  vesicle  bursts  and  dries,  the  base  of  it  swells  and 
enlarges,  other  vesicles  appear  in  circles  around  it,  and  there 
is  developed  an  "  anthrax  carbuncle,"  which  shows  a  black 
or  purple  elevation  with  a  central  depression  surrounded  by 
one  or  more  rings  of  vesicles.  Pain  is  trivial.  Lymphatic 
enlargements  occur.  Within  forty-eight  hours  after  the  pus- 
tule begins  microorganisms  appear  in  the  blood.  In  loose 
connective  tissue  the  lesion  may  be  anthrax  edema,  a  spreading 
livid  edema  followed   by  blebs   and  even  by  gangrene.     The 

'^  Medical  Record,  Sept.  5,  1896. 


ANTHRAX.  231 

constitutional  symptoms  may  rapidly  follow  the  local  lesion, 
but  may  be  deferred  for  a  week  or  more.  The  patient  feels 
depressed,  has  obscure  aches  and  pains,  and  is  feverish,  but 
usually  keeps  about  for  a  short  period.  After  a  time  he  is 
apt  to  develop  rigors,  high  irregular  fevers,  sweats,  acute  fugi- 
tive pains,  diarrhea,  delirium,  typhoid  exhaustion,  dyspnea, 
cough,  and  cyanosis.  The  carbuncle  of  anthrax  is  dis- 
tinguished from  ordinary  carbuncle  by  the  central  depression, 
the  adherent  eschar,  the  absence  of  pain,  tenderness,  and  the 
absence  of  suppuration  of  the  first,  as  contrasted  with  the 
elevated  center,  the  multiple  foci  of  suppuration  and  slough- 
ing, and  the  acute  pain  of  the  second.  Anthrax  edema  dif- 
fers from  cellulitis  in  the  absence  of  all  tendency  to  form 
pus,  and  from  malignant  edema  by  the  greater  tendency  of 
the  latter  to  result  in  gangrene.  If  anthrax  has  a  visible 
lesion  and  the  constitutional  symptoms  are  slight  or  absent, 
the  chance  of  cure  is  good. 

Treatment. — If  a  person  is  wounded  by  an  object  sus- 
pected of  carr}'ing  the  infection,  cauterize  the  wound  \\ith 
the  hot  iron.  A  sufferer  from  anthrax  must  be  isolated  in  a 
well-ventilated  room.  All  dressings  are  to  be  burnt,  all 
discharges  asepticized,  and  after  the  removal  of  the  patient 
the  bed-clothes  are  burnt  and  the  room  disinfected.  A 
malignant  pustule  should  be  entirely  excised,  and  the  wound 
mopped  out  with  pure  carbolic  acid  or  burnt  with  the  hot 
iron,  and  afterward  dressed  with  wet  bichloride-of-mercury 
gauze  which  is  covered  with  an  ice-bag.  Excision  should 
be  practised  even  when  glands  are  enlarged,  but  it  will  prove 
ineffectual  if  organisms  are  present  in  the  blood.  When 
excision  cannot  be  performed  make  crucial  inci.sions  through 
the  lesion,  mop  the  wounds  with  pure  carboHc  acid,  and  inject 
about  and  in  the  pustule  carbolic  acid  (i  :  10)  every  six  hours 
until  the  disease  abates  or  toxic  symptoms  appear.  The  adhe- 
rent eschar  is  subsequently  removed  by  hot  antiseptic  fomen- 
tations. Davaine  advised  the  following  plan  :  Inject  the  pus- 
tule and  the  tissues  about  it  at  many  points  every  eight  or 
ten  hours  with  i  part  of  tincture  of  iodin  diluted  with  2  parts 
of  water  or  with  a  10  per  cent,  solution  of  carbolic  acid,  or 
with  a  -^  per  cent,  solution  of  corrosive  sublimate.  Dress 
with  wet  antiseptic  gauze  and  apply  an  ice-bag.  The  skin 
over  inflamed  lymphatic  vessels  and  glands  should  be  painted 
with  iodin  and  smeared  with  ichthyol.  Constitutional  treat- 
ment must  be  sustaining  and  stimulating.  Maffucci  gives 
carbolic  acid  internally,  and  also  uses  it  externally.  Davies- 
Colley  uses  ipecac    locally  and    gives    large    doses   by    the 


232  COJVTUSIOI^S  AND    WOUNDS. 

mouth.  Pulmonary  anthrax  and  intestinal  anthrax  are  always 
fatal.     The  treatment  is  symptomatic. 

Hydrophobia,  Rabies,  or  Lyssa. — Hydrophobia  is  a 
spasmodic  and  paralytic  disease  due  to  infection  through  a 
wound  with  the  virus  from  a  rabid  animal.  The  animal 
may  be  a  dog,  a  cat,  a  Avolf,  a  fox,  or  a  horse.  Roux  esti- 
mates that  about  14  per  cent,  of  the  people  bitten  by  mad 
animals  develop  the  disease.  If  the  bite  is  on  an  exposed 
part,  it  is  far  more  apt  to  cause  rabies  than  if  the  teeth  pass 
through  clothing.  The  sali\'a  is  the  usual  vehicle  of  con- 
tagion, but  other  fluids  and  tissues  contain  the  virus,  espe- 
cially the  brain  and  cord.  Hydrophobia  has  been  known  for 
centuries.  At  the  present  day  some  ardent  antivivisectionists 
dispute  its  existence.  The  fact  that  it  can  occur  in  an  infant 
after  it  has  been  bitten  by  a  rabid  animal  proves  that  the 
disease  is  not  due  to  the  imagination.  Hydrophobia  is  almost 
invariably  fatal. 

Symptoms. — The  period  of  incubation  of  hydrophobia  is 
from  a  few  weeks  to  several  months,  and  it  has  been  alleged 
that  it  may  even  be  two  years.  The  initial  symptoms  are 
mental  depression,  anxiety,  headache,  malaise,  and  often  pain 
or  even  congestion  in  the  cicatrix,  which  symptoms  are 
quickly  followed  by  a  general  hyperesthesia,  pharyngeal 
spasms,  dyspnea  from  laryngeal  spasms,  and  constant  attempts 
to  expectorate  thick  mucus  which  forms  because  of  congestion 
of  the  air-passages.  Attempts  at  swallowing,  as  well  as  lights 
and  noises,  tend  to  bring  on  spasms,  hence  the  fear  of  liquids 
(there  is  spasm  from  attempts  at  swallowing,  and  even  in 
some  cases  from  thinking  of  the  act).  The  entire  body  may 
be  thrown  into  clonic  spasms,  but  there  is  no  tonic  spasm.  The 
mind  is  usually  clear,  although  during  the  periods  of  excite- 
ment there  may  be  maniacal  furor  with  hallucinations  which 
pass  avv^ay  in  the  stage  of  relaxation.  The  temperature  is 
moderately  elevated  (101°  to  103°  F.  or  higher).  The  spas- 
modic stage  lasts  from  one  to  three  days,  and  the  patient  may 
die  during  this  stage  from  exhaustion  or  from  asphyxia.  If 
he  lives  through  this  period,  the  convulsions  gradually  cease, 
the  power  of  swallowing  returns,  and  the  patient  succumbs 
to  exhaustion  in  less  than  twenty-four  hours,  or  he  develops 
ascending  paralysis  which  soon  causes  cardiac  and  respiratory 
failure. 

In  hydrophobia  death  is  practically  inevitable.  Almost 
all  cases  in  which  it  is  alleged  that  recovery  ensued  were  not 
true  hydrophobia,  but  hysteria.  Wood  says  that  in  hysteria, 
especially    among    boys,    "  beast-mimicry^ "  is  common,  the 


HYDROPHOBIA.  233 

sufferer  snarling  like  a  dog,  and  in  the  form  known  as  "spuri- 
ous hydrophobia,"  in  which  there  may  or  may  not  be  convul- 
sion, there  are  a  dread  of  water,  emotional  excitement,  snarl- 
ing, and  attempts  to  bite  the  bystanders  (in  genuine  hydro- 
phobia no  attempts  are  made  to  bite,  and  no  sounds  are  uttered 
like  those  made  by  a  dog). 

Lyssa  is  separated  from  lockjaw  b\'  the  spasms  of  the 
larynx  and  the  absence  of  tonic  spasms  in  the  former,  as 
contrasted  with  the  fixation  of  the  jaws  and  the  tonic  spasms 
with  clonic  exacerbations  of  lockjaw. 

Treatment. — When  a  person  is  bitten  by  a  supposed  rabid 
animal  and  is  seen  soon  after  the  injur}',  constriction  should  be 
applied  if  possible  above  the  wound,  the  wounded  area  should 
be  excised,  cauterized  with  a  hot  iron  or  the  Paquelin  cau- 
ter}%  and  dressed  antisepticalh".  If  the  patient  is  not  seen 
for  a  number  of  hours  or  a  day  or  two  after  the  injur}-, 
cauterization  is  useless  ;  and  it  is  not  onh^  useless,  but  it  ma}- 
delude  the  patient  and  his  friends  with  a  feeling  of  securit}-. 
In  am'  case,  send  the  patient  at  once  to  a  Pasteur  institute. 
If  the  animal  which  inflicted  the  injur}-  was  not  h}-dro- 
phobic,  no  harm  will  result  from  inoculations  ;  if  it  was 
h}'drophobic,  preventi\-e  treatment  ma}'  save  the  patient.  The 
method  known  as  the  preventi\-e  treatment  was  de\-ised  b}- 
Pasteur,  who  discovered  the  following  remarkable  facts  :  If 
the  virus  of  a  rabid  dog  (street  rabies)  be  placed  beneath  the 
dura  of  another  dog,  it  ahvays  causes  h}^drophobia  in  from 
sixteen  to  twent}^  days,  and  invariabh'  causes  death.  If  the 
virus  is  passed  through  a  series  of  rabbits  it  gets  stronger 
(laborator}'  virus),  and  if  inserted  beneath  the  dura  of  a  dog 
it  causes  the  disease  in  from  five  to  six  da}-s,  and  kills  in 
four  or  five  days.  The  virus  can  be  attenuated  b}'  passing  it 
through  a  series  of  monke}-s  or  b}'  keeping  it  for  a  definite 
time.  To  obtain  attenuated  preparations  in  a  con^-enient  form 
Pasteur  made  emulsions  from  the  spinal  cords  of  h}^dro- 
phobic  rabbits,  the  animals  ha\-ing  been  dead  two  or  three 
weeks.  He  found  that  the  emulsion  obtained  from  the  rabbit 
longest  dead  is  the  weakest.  He  injected  a  dog  with  emul- 
sions of  progressiveh'  increasing  strength  and  made  it  im- 
mune to  h}-drophobia.  The  patient  is  injected  with  an  emul- 
sion made  from  the  dried  spinal  cords  of  h}-drophobic  rabbits. 
In  this  emulsion  the  virus  is  attenuated,  and  da}-  b}-  da}-  the 
strength  of  the  injected  virus  is  increased.  These  emulsions 
cause  the  body-cells  to  form  antitoxin,  and  either  the  virus 
of  street  rabies  does  not  develop  at  all  or  b}-  the  time  it 
begins  to  develop  a  quantit}*  of  antitoxin  is  present  to  an- 


234  CONTUSIONS  AND    WOUNDS. 

tagonize  it.  In  the  New  York  Pasteur  Institute  patients 
remain  under  treatment  for  fifteen  days,  two  inoculations 
being  given  daily.  In  cases  in  which  treatment  was  begun 
late,  or  in  which  the  head  or  face  was  bitten,  from  four  to  six 
inoculations  are  given  each  day.  The  report  of  the  Parisian 
Pasteur  Institute  shows  that  since  its  foundation  there  has 
been  a  mortality  of  0.5  per  cent.  The  lowest  estimated 
number  of  those  attacked  by  hydrophobia  before  this  method 
was  used  was  5  per  cent,  of  those  bitten,  and  all  attacked 
died ;  hence,  the  Pasteur  treatment  shows  one-twenty-fifth 
of  the  mortality  which  attends  other  preventive  methods. 
The  value  of  this  plan  seems  definitely  established.  The 
general  public  believe  that  the  dog  which  did  the  biting 
should  be  killed.  The  dog  should,  if  possible,  be  locked  up 
and  watched  rather  than  killed.  It  may  be  proved  in  this 
way  that  the  dog  did  not  have  hydrophobia.  If  it  were 
necessary  to  kill  the  dog  or  if  the  dog  was  killed  at  once  or 
soon  after,  the  physicians  of  the  New  York  Pasteur  Institute 
advise  that  the  dog's  head  be  cut  from  the  body  with  an 
aseptic  knife  and  a  piece  of  the  medulla  oblongata  be  ab- 
stracted. The  bit  of  medulla  is  placed  in  a  mixture  of  equal 
parts  of  glycerin  and  water  which  was  previously  sterilized 
by  boiling.  The  bottle  should  be  sealed  and  sent  to  the 
Institute,  in  order  that  inoculations  may  be  made  upon  ani- 
mals to  prove  the  existence  or  absence  of  hydrophobia. 
Murri,  of  Bologna,  cured  a  case  of  hydrophobia  by  injecting 
emulsions  of  cords  of  rabbits  dead  six,  five,  four,  and  three 
days  respectively.  It  would  be  proper  to  try  this  remedy 
if  hydrophobia  develops.  In  the  paroxysm  of  hydrophobia 
the  treatment  in  the  past  was  purely  palliative.  If  we  employ 
only  palliative  methods,  keep  the  patient  in  a  dark,  quiet 
room,  relieve  thirst  by  enemata,  saturate  him  with  morphin, 
empty  the  bowels  by  enemata,  attend  to  the  bladder,  and 
during  the  paroxysms  anesthetize. 

Glanders,  Farcy,  or  Hqtiinia. — Glanders  is  an  infec- 
tious eruptive  fever  occurring  in  horses  and  communicable  to 
man.  If  the  nodules  occur  in  a  horse's  nares,  the  disease  is 
called  "  glanders  ;"  if  beneath  the  skin,  it  is  termed  "  farcy." 
This  disease  is  due  to  a  bacillus,  and  is  communicated  to  man 
through  an  abraded  surface  or  a  mucous  membrane  (Osier). 
The  characteristic  lesions  are  infecti\'e  granulomata,  which  in 
the  nose  form  ulcers  and  under  the  skin  develop  into  abscesses. 

Acute  and  Chronic  Glanders. — In  acute  glanders  there  is 
septic  inflammation  at  the  point  of  inoculation  ;  nodules  form 
in  the  nose,  and  ulcerate  ;  there  is  profuse  nasal  discharge  ; 


A  C  TINOM  YCOSIS.  235 

the  glands  of  the  neck  enlarge ;  there  are  fever  and  an  erup- 
tion like  small-pox  on  the  face  and  about  the  joints  (Osier), 
and  severe  muscular  pain.  Acute  glanders  is  always  fatal. 
Chronic  glanders  lasts  for  months,  is  rarely  diagnosticated, 
being  mistaken  for  catarrh,  and  is  often  recovered  from. 
The  diagnosis  can  be  made  by  injecting  a  guinea-pig  with 
the  nasal  mucus. 

Acute  and  Chronic  Farcy. — Acute  farcy  arises  at  the  site 
of  a  skin-inoculation  ;  it  begins  as  an  intense  inflammation, 
from  which  run  out  inflamed  lymphatics  that  present  nodules 
or  "  farcy-buds."  Abscesses  form.  There  are  joint-pain  and 
the  constitutional  symptoms  of  sepsis,  but  no  involvement 
of  the  nares.  Chronic  farcy  may  last  for  months.  In  it 
nodules  occur  upon  the  extremities,  which  nodules  break 
down  into  abscesses  and  eventuate  in  ulcers  resembling 
those  of  tuberculosis. 

Treatment. — In  treating  this  disease  the  point  of  infection 
is  at  once  to  be  incised  and  cauterized,  dusted  with  iodoform, 
and  dressed  antiseptically.  The  skin  over  enlarged  glands 
and  swollen  lymphatics  is  to  be  painted  with  iodin  and 
smeared  with  ichthyol.  Bandages  are  applied  to  edematous 
extremities.  Ulcers  are  curetted,  touched  with  pure  carbolic 
acid,  dusted  with  iodoform,  and  dressed  antiseptically.  The 
nostrils  should  be  sprayed  at  frequent  intervals  with  peroxid 
of  hydrogen,  and  frequently  syringed  with  a  solution  of  sul- 
phurous acid.  The  mouth  must  be  rinsed  repeatedly  with 
solutions  of  chlorate  of  potassium.  Abscesses  are  to  be 
opened,  mopped  with  pure  carbolic  acid,  and  dressed  anti- 
septically. Stimulants  and  nourishing  diet  are  imperatively 
demanded.  Morphin  is  necessary  for  the  muscular  pain, 
restlessness,  and  insomnia.  Digitalis  is  given  to  stimulate 
the  circulation  and  kidney  secretion.  Sulphur  iodid,  arsenite 
of  strychnin,  and  bichlorate  of  potassium  have  been  used. 
Diseased  horses  ought  at  once  to  be  killed  and  their  stalls 
ought  to  be  torn  to  pieces,  purified,  and  entirely  rebuilt.  A 
man  with  chronic  glanders  should  be  removed  to  the  seaside. 
The  nasal  passages  should  be  kept  clean  and  the  ulcers 
must  be  cauterized  and  dressed  with  iodoform  gauze.  Nutri- 
tious foods,  tonics,  and  stimulants  are  necessary. 

Actinomycosis  is  an  infectious  disorder  characterized  by 
chronic  inflammation,  and  is  due  to  the  presence  in  the  tis- 
sues of  the  actinoniyccs,  or  ray-fungus.  This  disease  occurs 
in  cattle  (lumpy  jaw)  and  in  pigs,  and  can  be  transmitted  to 
man,  usually  by  the  food.  At  the  point  of  inoculation  (which 
is  generally  about  the  mouth)  arises  an  infective  granuloma, 


236  CONTUSIONS  AND    WOUNDS. 

around  which  inflammation  of  connective  tissue  occurs,  sup- 
puration eventually  taking  place.  Inoculation  in  the  mouth 
is  by  way  of  an  abrasion  of  mucous  membrane  or  through 
a  carious  tooth.  Chewing  straw  which  contains  the  fungi  is 
the  most  common  method  of  infection.  The  ray-fungi  may 
pass  into  the  lungs,  causing  pulmonary  actinomycosis  ;  into 
the  intestines,  causing  intestinal  actinomycosis  ;  into  the  skin, 
the  bones,  the  subcutaneous  tissues,  the  heart,  the  brain,  the 
liver,  etc.  Cases  of  human  actinomycosis  until  very  recently 
were  looked  upon  as  sarcomata. 

Cutaneous  actinomycosis  may  be  secondaiy  to  a  visceral 
area  of  disease,  may  be  a  purely  local  condition,  or  may  be 
associated  with  some  adjacent  area  of  bone-infection.  The 
gummatous  form  of  the  disease  resembles  a  gummatous 
syphilitic  area,  and  in  it  many  small  purulent  pockets  open 
by  iistulse  (Monestie). 

In  the  anthracoid  form  there  are  no  distinct  purulent  collec- 
tions, but  many  fistulae  discharge  pus  at  various  points 
(Monestie). 

An  area  of  cutaneous  actinomycosis  is  characterized  by  the 
existence  of  violet,  blue,  gray,  or  black  maculae,  varying  in 
size  from  that  of  a  pin's  head  to  that  of  a  bean,  the  center 
of  each  macule  being  white  and  containing  a  minute  quantity 
of  pus  (Derville). 

The  pus  of  actinomycosis  contains  many  sulphur-yellow 
bodies,  visible  to  the  naked  eye  and  composed  of  fungi. 
These  bodies  feel  gritty  when  rubbed  between  the  fingers 
because  of  the  presence  of  lime  salts. 

In  actinomycosis  of  bone  the  bone  enlarges  and  becomes 
painful,  the  parts  adjacent  swell  from  infiltration  and  soften, 
pus  forms  and  reaches  the  surface  through  fistulae,  and  the 
skin  often  becomes  involved  secondarily. 

In  actinomycosis  the  adjacent  lymphatic  glands  are  not 
involved.  The  diagnosis  must  be  made  from  syphilis,  sar- 
coma, and  tuberculosis.  The  microscopic  examination  of  the 
pus  makes  the  diagnosis. 

Treatment. — Free  excision  if  possible  ;  otherwise  incision, 
cauterization  with  pure  carbolic  acid,  and  packing  with  iodo- 
form gauze.  Give  internally  large  doses  of  iodid  of  potas- 
sium.    This  drug  alone  has  cured  many  cases.  ^ 

Wounds  of  Mucous  Membranes. — If  the  surgeon  in- 
tends to  inflict  a  wound  upon  a  mucous  surface,  he  should 
see  to  it  that  the  patient's  general  condition  is  good.  Thor- 
ough asepsis  is  impossible,  and  a  good  result  depends  largely 
upon    the    vital    resistance  of  the  tissues.     Before  operating 


SYPHILIS.  237 

irrigate  the  part  frequently  with  boric  acid,  peroxid  of  hydro- 
gen, or  normal  salt  solution.  When  ready  to  sew  up  the 
wound  be  sure  that  all  irritant  fluids  are  removed  (saliva  in 
the  mouth,  etc.).  Cleanse  the  wound  with  hot  normal  salt 
solution.  The  stitches  must  include  submucous  tissue  as 
well  as  the  mucous  membrane,  and  consist  of  silver  wire,  silk, 
or  silkworm-gut.  After  sewing  up  a  wound  in  the  mouth, 
wash  at  frequent  inter\-als  with  salt  solution,  and  follow  each 
washing  with  the  insufflation  of  iodoform. 

In  accidental  wounds  irrigate  with  salt  solution,  dust  \\\\h. 
iodoform,  and  close  as  directed  above.  Corrosive  sublimate 
is  so  irritant  that  it  does  harm  when  applied  to  a  mucous 
membrane. 

XVI.   SYPHILIS. 

Definition. — Syphilis  is  a  chronic  contagious,  and  some- 
times hereditary',  constitutional  disease.  Its  iirst  lesion  is  an 
infecting  area  or  chancre,  which  is  followed  b\'  h'mphatic  en- 
largements, eruptions  upon  the  skin  and  mucous  membranes, 
affections  of  the  appendages  of  the  skin  (hair  and  nails), 
"  chronic  inflammation  and  infiltration  of  the  cellulovascular 
tissue,  bones,  and  periosteum"  (White),  and,  later,  often  by 
gummata.  This  disease  is  probably  due  to  a  microbe,  but 
Lustgarten's  bacillus  has  not  been  proved  to  be  the  cause.  One 
fact  against  its  being  the  cause  is  its  presence  in  the  non-con- 
tagious late  gummata.  \\'hite  quotes  Fenger  in  his  assump- 
tion that  syphilitic  fever  is  due  to  absorption  of  toxins  ;  that 
the  eruptions  of  skin  and  mucous  membranes  in  the 
secondar}'  stage  arise  from  local  deposit  and  multiplication 
of  the  virus ;  that  many  secondar}'  symptoms  result  from 
nutritive  derangement  caused  by  tissue-products  passing  into 
the  circulation ;  that  the  virus  exists  in  the  body  after  the 
cessation  of  secondar}'  s\-mptoms  ;  and  that  it  may  die  out 
or  may  awaken  into  activity,  producing  "  reminders." 

During  the  primarv-  and  secondar}-  stages  fresh  poison  can- 
not infect,  and  this  is  true  for  a  time  after  the  disappearance 
of  secondary  symptoms.  Immunit}'  in  the  primar}-  stage  is 
due  to  products  absorbed  from  the  infected  area.  Colles's 
immunity  is  that  acquired  by  mothers  who  have  borne  s}'ph- 
ilitic  children,  but  who  themselves  show  no  sign  of  the  dis- 
ease. Profeta's  immunity'  is  the  immunit}-  against  infection 
possessed  by  many  healthy  children  bom  of  syphilitic  par- 
ents. Tertiar}'  syphilitic  lesions  are  not  due  to  the  poison 
of  syphilis,  but  to  tissue-products  resulting  from  the  action 


238  SYPHILIS. 

of  that  poison,  or  to  nutritive  failure  as  a  consequence  of  the 
disease.  Tertiary  syphihs  is  not  transmissible,  but  it  secures 
immunity. 

Transmission  of  Syphilis.--This  disease  can  be  trans- 
mitted— (i)  by  contact  with  the  tissue-elements  or  virus — 
acqtih'ed  syphilis  ;  and  (2)  by  hereditary  transmission — hered- 
itary syphilis.  The  poison  cannot  enter  through  an  intact 
epidermis  or  epithelial  layer,  and  abrasion  or  solution  of  con- 
tinuity is  requisite  for  infection.  Syphilis  is  usually,  but  not 
always,  a  venereal  disease.  It  may  be  caught  by  infection 
of  the  genitals  during  coition,  by  infection  of  the  tongue  or 
lips  in  kissing,  by  smoking  poisoned  pipes,  by  drinking  out 
of  infected  vessels,  or  by  beastly  practices.  The  initial  lesion 
of  syphilis  may  be  found  on  the  finger,  penis,  eyelid,  lip, 
tongue,  cheek,  palate,  anus,  nipple,  etc.  A  person  may  be 
a  host  for  syphilis,  carry  it,  give  it  to  another,  and  yet  escape 
it  himself  (a  surgeon  may  carry  it  under  his  nails,  and  a 
woman  may  have  it  lodged  in  her  vagina).  Syphilis  can  be 
transmitted  by  vaccination  with  human  lymph  which  contains 
the  pus  of  a  syphilitic  eruption  or  the  blood  of  a  syphilitic 
person.  Vaccine  lymph,  even  after  passage  through  a  per- 
son with  pox,  will  not  convey  syphilis  if  it  is  free  from  blood 
and  the  pus  of  specific  lesions  ;  it  is  not  the  lymph  that 
poisons,  but  some  other  substance  which  the  lymph  may 
carry. 

Syphilitic  Stages. — Syphilis  was  divided  by  Ricord 
into  three  stages  :  (i)  the  primary  stage — chancre  and  indo- 
lent bubo ;  (2)  the  secondary  stage — disease  of  the  upper 
layer  of  the  skin  and  mucous  membranes ;  and  (3)  the 
tertiary  stage — affections  of  connective  tissues,  bones,  fibrous 
and  serous  membranes,  and  parenchymatous  organs.  This 
division,  which  is  useful  clinically,  is  still  largely  employed, 
but  it  is  not  so  shaip  and  distinct  as  was  believed  by  Ricord ; 
it  is  only  artificial.  For  instance,  ozena  may  develop  during 
a  secondary  eruption,  and  bone  disease  may  appear  early  in 
the  case. 

Syphilitic  Periods. — White  divides  the  pox  into  the 
following  periods:  (i)  period  oi  primary  incubation — the 
time  between  exposure  and  the  appearance  of  the  chancre : 
from  ten  to  ninety  days,  the  average  being  three  weeks ;  (2) 
period  of  p^dmary  symptoms — chancre  and  bubo  of  adjacent 
lymph-glands ;  (3)  period  of  secondary  incubation — the  time 
between  the  appearance  of  the  chancre  and  the  advent  of 
secondary  symptoms  :  about  six  weeks  as  a  rule  ;  (4)  period 
of  secondary  symptoms — lasting  from  one  to  three  years  ;  (5) 


PRIMARY  SYPHILIS.  239 

intcruicdiatc  period — there  may  be  no  symptoms  or  there 
may  be  light  symptoms  which  are  less  symmetrical  and  more 
general  than  those  of  the  secondary  period :  it  lasts  from  two 
to  four  years,  and  ends  in  recovery  or  tertiary  syphilis  ;  and 
(6)  period  of  tertiary  symptoms — indefinite  in  duration.  The 
fifth  and  sixth  periods  may  never  occur,  the  disease  having 
been  cured. 

Primary  Syphilis. — The  primary  stage  comprises  the 
chancre  or  infecting  sore  and  bubo.  A  chancre  or  initial 
lesion  is  an  infective  granuloma  resulting  from  the  poison  of 
syphilis.  A  chancre  may  be  derived  from  the  discharges  of 
another  chancre,  from  the  secretion  of  mucous  patches  and 
moist  papules,  from  syphilitic  blood,  or  from  the  pus  or 
secretion  of  any  secondary  lesion.  Tertiary  lesions  cannot 
cause  chancre.  It  appears  at  the  point  of  inoculation,  and  is 
the  first  lesion  of  the  disease.  During  the  three  weeks  or 
more  requisite  to  develop  a  chancre  the  poison  is  continuously 
entering  the  system,  and  when  the  chancre  develops  the 
system  already  contains  a  large  amount  of  poison.  A 
chancre  is  not  a  local  lesion  from  which  syphilis  springs,  but 
is  a  local  manifestation  of  an  existing  constitutional  disease, 
hence  excision  is  entirely  useless.  If  we  take  the  discharge 
of  a  chancre  and  insert  it  at  some  indifferent  point,  into  the 
person  from  whom  we  took  it,  a  new  indurated  chancre  will 
not  be  formed,  because  the  individual  already  has  syphilis, 
but  auto-inoculation  with  the  discharge  of  an  irritated  chancre 
can  cause  a  non-indurated  sore.  If  we  take  the  discharge 
of  a  chancre  and  insert  it  into  a  healthy  person,  an  indurated 
chancre  follows.  Hence  we  say  that  primary  syphilis  is  not 
auto-inoculable,  but  is  hetero-inoculable.  A  soft  sore  can 
be  produced  in  the  lower  animals  by  inoculation  with  the 
virus  of  a  chancre,  but  a  hard  sore  cannot.  Some  observers, 
notably  Kaposi,  of  Vienna,  advocate  the  unity  theory.  This 
theory  maintains  that  both  hard  and  soft  sores  are  due  to  the 
same  virus,  the  infective  power  of  the  soft  chancre  simply 
being  less  than  that  of  the  hard  sore,  the  possibility  of  con- 
stitutional infection  depending,  not  upon  differences  in  the 
poison,  but  rather  upon  differences  in  the  soil  and  in  the 
local  processes.  The  unicists  advocate  excision  of  chancres, 
soft  or  hard,  to  prevent,  if  possible,  constitutional  involve- 
ment. Most  syphilographers  believe  in  the  duality  theory, 
which  Ave  have  previously  set  forth.  This  theory  took  origin 
from  the  classical  investigations  of  Bassereau  and  Rollet. 
The  duality  theory  maintains  that  the  soft  sore  is  caused  by 


240  SYPHILIS. 

a  poison  different  from  that  which  originates  the  hard  sore, 
and  that  a  true  soft  sore  never  infects  the  system.' 

Initial  I/esions. — An  initial  lesion,  hard  chancre,  or 
infecting  sore  never  appears  until  at  least  ten  days  after 
exposure ;  it  may  not  appear  for  many  weeks,  but  it  usually 
arises  in  about  twenty-five  days.  There  are  three  chief 
forms  of  initial  lesion:  (i)  a  purple  patch  exposed  by  peeling 
epidermis,  without  induration  and  ulceration — a  rare  form ; 
(2)  an  indurated  area  under  the  epidermis,  without  ulceration 
— a  very  common  form ;  and  (3)  a  round,  indurated,  carti- 
laginous area  with  an  elevated  edge,  which  ulcerates,  expos- 
ing a  velvety  surface  looking  like  raw  ham ;  it  bleeds  easily, 
rarely  suppurates,  does  not  spread,  and  the  discharge  is  thin 
and  watery.  This  is  the  "  Hunterian  chancre,"  which  is  rarer 
than  the  second  variety,  but  commoner  than  the  first,  and 
which  ulcerates  because  of  dirt,  caustic  applications,  or  friction. 

A  chancre  is  rarely  multiple ;  but  if  it  is  so,  all  the  sores 
appear  together  as  a  result  of  the  primary  inoculation  ;  they 
do  not  follow  one  another  because  of  auto-infection.  A  hard 
sore  does  not  suppurate  unless  irritated  by  caustics,  friction, 
or  dirt,  or  unless  there  be  mixed  infection  with  chancroid ; 
its  nature  is  not  to  suppurate.  The  hardness  may  affect  only 
the  base  and  margins  of  an  ulcer  or  it  may  affect  considerable 
areas,  but  it  has  well-defined  margins  and  feels  like  cartilage 
encapsuled,  so  that  it  can  be  picked  up  between  the  fingers. 
This  hardness  or  sclerosis  is  due  to  gradual  inflammatory 
exudation  into  "  the  tissues  at  the  base  of  the  ulcer  and  to 
growth  of  the  nodule  "  (von  Zeissl).  It  feels  distinct  from 
the  surrounding  tissues,  like  a  foreign  body  lying  in  the  part. 
A  chancre  untreated  may  last  many  months.  The  indura- 
tion usually  disappears  soon  after  the  appearance  of  secondary 
symptoms.  A  copper-colored  spot  remains,  and  does  not 
disappear  until  the  disease  is  cured.  Induration  may  again 
appear  before  the  outbreak  of  some  distant  lesion. 

Mixed  Infection  of  Chancre  and  Chancroid. — Von 
Zeissl  says :  "  If  syphilitic  contagion  is  mixed  with  pus,  a 
chancre  begins  as  a  circumscribed  area  of  hyperemia  and 
swelling,  which  undergoes  ulceration,  and  does  not  develop 
hardness  for  a  period  of  from  ten  days  to  several  weeks,  and 
may  develop  a  nodule  after  the  first  ulcer  has  entirely  healed." 
This  condition  is  seen  when  mixed  infection  occurs,  the  chan- 
croid poison  being  quick,  and  the  syphilitic  poison  being 
slow,  to  act.     If  chancroid    poison  is  deposited    some  time 

'  For  a  full  discussion  of  these  points  see  the  writings  of  Fournier,  Alfred 
Cooper,  and  von  Zeissl,  and  especially  the  great  work  of  Taylor. 


CHAXCjRE.  241 

after  the  syphilitic  poison  has  been  absorbed,  the  induration 
may  appear  in  a  few  days  after  the  chancroid  begins.  A  soft 
chancre  may  appear  upon  an  existing  syphilitic  nodule  and 
may  eat  out  the  induration. 

Diagnosis  of  Chancre. — It  is  necessary  to  distinguish  a 
chancre  from  a  chancroid  and  from  ulcerated  herpes.  A  chan- 
croid appears  in  from  two  to  fi\"e  days  after  contagion  (ahva}-s 
less  than  ten  days) ;  it  ma}'  be  multiple  from  the  start,  but,  e\"en 
if  beginning  as  one  sore,  other  sores  appear  by  auto-inoculation ; 
it  begins  as  a  pustule,  which  bursts  and  exposes  an  ulcer ; 
the  ulcer  is  circular,  has  thin,  sharp-cut,  or  undermined  edges, 
a  sloughy,  non-granulating  base,  and  gives  origin  to  a  thin, 
purulent,  ofiensive  discharge  which  is  both  auto-  and  hetero- 
inoculable.  These  soft  sores  have  no  true  sclerotic  area,  do 
not  bleed,  produce  no  constitutional  symptoms,  and  are  apt  to 
be  followed  by  acute  inflammator}'  buboes  which  tend  to 
suppurate.  A  chancroid  causes  pain,  and  the  original  ulcer 
enlarges  greath*.  A  chancre  appears  in  about  twenty-fi\"e 
da}'s  after  inoculation  (ne\'er  before  ten  da}-s) ;  it  is  generally 
single,  but  if  multiple  sores  exist,  they  all  appear  together, 
for  their  discharge  is  not  auto-inoculable  if  the  sore  is  not 
irritated;  an  auto-inoculation  of  the  products  of  an  irritated 
chancre  can  at  most  produce  only  a  soft  purulent  ulcer.  A 
chancre  begins  as  an  excoriation  or  as  a  nodule ;  if  an  ulcer 
forms,  its  floor  is  covered  with  granulations  and  it  is  red  and 
smooth  ;  the  discharge  is  thin  and  scant}-  and  not  oftensi\-e  ; 
the  edges  are  tliick  and  sloping ;  it  is  surrounded  by  an  area 
of  induration,  and  bleeds  when  touched,  there  appear  about 
the  same  time  with  it  indolent  multiple  enlargements  of  the 
adjacent  glands,  which  rareh'  suppurate,  and  it  is  followed 
by  secondar}'  s}-mptoms.  A  chancre  causes  little  pain,  and 
after  it  has  existed  for  a  few  da}"s  rarely  shows  an}-  tendenc}- 
to  spread.  A  urethral  chancre  appears  at  the  usual  period 
of  incubation  :  it  is  situated  near  the  meatus,  one  lip  of  which 
is  usuall}-  indurated ;  the  discharge  is  slight,  often  blood}-, 
and  never  purulent  ;  indurated  multiple  buboes  arise ;  the 
sore  can  be  seen,  and  constitutional  symptoms  tollow. 

Herpetic  ulceration  has  no  period  of  incubation  ;  it  may 
follow  fever,  but  usuall}-  arises  from  friction  or  irritation  due 
to  dirt  or  acrid  discharges.  It  appears  as  a  group  of  vesicles, 
all  of  which  ma}-  dry  up,  or  some  may  diy  up  and  others 
ulcerate,  or  they  ma}-  run  together  and  ulcerate.  The  edges  of 
a  herpetic  ulcer  are  in  "  segments  of  small  circles  "  (White) ; 
the  ulcer  is  superficial,  has  but  little  discharge,  and  does  not 
have  much  tendency  to  spread  ;  it  has  no  induration  ;  it  is 

16 


242  sv Pin  LIS. 

painful ;  it  is  not  accompanied  by  bubo  unless  suppuration  is 
extensive.  Herpes  is  not  followed  b}-  constitutional  involve- 
ment. 

A  chancre  may  be  mistaken  for  cancer  of  the  tongue. 
"  A  chancre  of  this  region  is  brownish-red.  a  cancer  being 
bright  red.  A  chancre  is  soft  in  the  center ;  a  cancer  pre- 
sents uniformity  of  induration.  A  chancre  gives  origin  to  a 
thin,  purulent  discharge,  free  from  blood  ;  a  cancer  furnishes 
a  non-purulent,  bloody  discharge.  A  chancre  is  followed 
by  indolent  lymphatic  enlargements  under  the  jaw  ;  a  cancer 
is  followed  by  painful  enlargements."  A  cancer  is  slower 
in  evolution,  is  not  followed  by  constitutional  symptoms,  and 
the  lymphatic  enlargements  are  much  later  in  appearing  than 
in  chancre. 

Phagedena. — A  chancre  or  a  chancroid  may  be  attacked 
by  phagedena,  a  destructive  form  of  ulceration  which  was 
once  common,  but  at  present  is  rare.  The  ulceration  often 
spreads  on  all  sides  and  also  deeply  into  the  tissues.  In 
some  cases  it  spreads  in  only  one  direction  (serpiginous  ulcera- 
tion ),  in  some  cases  sloughing  occurs.  Phagedena  occurs 
only  in  the  debilitated  (anemic,  drunkards,  strumous  sub- 
jects, sufferers  from  diabetes,  Bright's  disease,  etc.;  salivation 
can  cause  it).  The  phagedenic  ulcer  is  irregular,  with  con- 
gested and  edematous  edges,  and  a  foul,  sloughy  floor. 

Chancre  Redux. — Some  observers  believe  that  reinfec- 
tion with  syphilis  is  not  very  unusual  (Hutchinson).  Most 
authorities  maintain  that  it  is  very  rare  (Taylor).  The  latter 
school  maintains  that  the  region  once  occupied  by  a  chancre 
may,  after  many  years,  become  indurated  anew.  Fournier 
pointed  out  this  fact  thirty  years  ago.  Such  a  reinduration  is 
called  chancre  redux,  or  relapsing  chancre. 

If  syphilitic  manifestations  follow  such  an  induration,  we 
must  conclude  that  reinfection  has  truly  occurred.  If  they 
do  not  follow^  and  this  is  the  rule,  the  lesion  is  not  really  a 
chancre,  but  is  probably  a  gumma  in  an  early  stage  of 
development.     Mauriac  pointed  out  this  last  fact.^ 

Syphilitic  Bubo. — In  syphilitic  bubo  anatomically  re- 
lated lymphatic  glands  enlarge  about  the  same  time  as  indu- 
ration of  the  initial  lesion  begins.  In  the  ver>'  beginning 
these  glands  maybe  a  little  painful,  but  the  pain  is  slight  and 
of  temporary  duration.  These  enlargements  are  called  "  indo- 
lent buboes ;  "  they  may  be  as  small  as  peas  or  as  large  as 
walnuts,  are  freely  movable,  and  ver}^  rarely  suppurate.     The 

'  Mracek,  in  Wien.  kliji.  Rundschau,  1896.  H.  G.  Antony,  in  Chicago  Med- 
ical Recorder,  April,  1S99. 


GENERAL    SYPHILIS.  243 

lesion  of  the  glands  is  hyperplasia  of  all  the  gland-elements 
and  of  their  capsules,  due  to  absorption  of  the  virus.  If  the 
patient  is  tubercular,  the  bubo  is  apt  to  become  enormous, 
lobulated,  and  persistent.  If  the  chancre  appears  on  the  penis, 
the  superficial  inguinal  and  femoral  glands  enlarge,  usually  on 
the  same  side  of  the  body  as  the  sore.  If  the  sore  is  on  the 
frenum,  both  groins  are  involved.  If  a  chancre  appears  on 
the  lip  or  tongue,  the  bubo  is  beneath  the  jaw.  These 
buboes  may  remain  for  many  months  ;  they  do  not  suppu- 
rate unless  the  sore  suppurates  or  unless  the  patient  is  of 
the  tubercular  type  ;  and  they  finally  disappear  by  absorp- 
tion or  fatty  degeneration.  About  six  weeks  after  buboes 
have  formed  in  the  glands  related  to  the  lesion  all  the  lym- 
phatics of  the  body  enlarge.  General  l}"mphatic  involve- 
ment arises  about  the  same  time  as  the  secondary  eruption. 
The  enlargement  of  the  post-cervical  and  epitrochlear  glands 
is  diagnostically  important.  Glandular  enlargements  persist 
until  after  the  eruptions  have  disappeared. 

Glandular  enlargement  always  occurs  in  syphilis,  but  the 
bubo  exists  in  only  one-third  of  the  chancroid  cases.  The  bubo 
of  syphilis  is  multiple,  consisting  of  a  chain  of  movable  glands 
(the  glandulse  Pleiades  of  Ricord) ;  the  bubo  of  chancroid  is 
one  inflamed  and  immovable  mass.  The  bubo  of  syphilis 
is  indurated,  painless,  small,  and  slow  in  growth ;  the  bubo 
of  chancroid  shows  inflammatory  hardness,  is  painful,  large, 
and  rapid  in  growth  ;  the  first  rarely  suppurates,  the  second 
often  does.  The  skin  over  a  syphilitic  bubo  is  normal ;  that 
over  a  chancroidal  bubo  is  red  and  adherent.  A  syphilitic 
bubo  is  not  cured  by  local  treatment,  but  is  cured  by  the  in- 
ternal use  of  mercury  and  is  followed  by  secondary  symp- 
toms. A  chancroidal  bubo  requires  local  treatment,  is  not 
cured  by  mercury,  and  is  not  followed  by  secondaries. 
Herpes,  balanitis,  and  gonorrhea  rarely  cause  bubo,  but 
when  they  do  the  bubo  in  each  case  is  similar  to  that  caused 
by  chancroid.  A  positive  diagnosis  of  syphilis  can  be  made 
when  an  indurated  sore  is  followed  by  multiple  indolent  bu- 
boes in  the  groin  and  by  enlargement  of  distant  glands. 

General  Syphilis. — As  the  general  lymphatic  enlarge- 
ment becomes  manifest  there  is  apt  to  appear  a  group  of 
s}'mptoms  known  as  "  s\'philitic  fever."  The  patient  usually 
thinks  he  has  a  severe  cold,  is  feverish  and  restless ;  com- 
plains of  sleeplessness  and  anorexia  ;  his  face  is  pale  ;  he 
has  intermitting  rheumatoid  pains  in  the  joints  and  muscles, 
especially  of  the  shoulders,  arms,  chest,  and  back,  which 
pains    change  their  location   constantly  and  prevent    sleep ; 


244  SYPHILIS. 

nightsweats  occur,  and  the  pulse  is  quite  frequent.  The 
fever  usually  reaches  its  height  in  forty-eight  hours,  and  falls 
as  the  eruption  develops.  Syphilitic  fever  does  not  occur 
in  every  case.  It  may  reappear  during  the  progress  of  the 
disease. 

Secondary  Syphilis. — The  phenomena  of  secondary 
syphilis  are  due  to  poisoned  blood.  Fenger  states  that  the 
poison  is  present  in  the  blood  during  outbreaks,  but  not  dur- 
ing the  quiescent  periods  between  outbreaks.  Secondary 
syphilis  is  characterized  by  plastic  inflammation,  by  the  for- 
mation of  fibrous  tissue,  and  by  thickening  of  tissue.  Super- 
ficial ulcerations  may  occur.  Structural  overgrowths  appear 
(for  instance,  warts). 

Syphilitic  Skin  Diseases. — SypJiilodennata  (syphilides) 
are  due  to  circumscribed  inflammation,  and  may  be  dry  or  pur- 
ulent. There  is  no  one  eruption  characteristic  of  syphilis. 
This  disease  may  counterfeit  any  skin  disease,  but  it  is  an  imi- 
tation which  is  not  perfect  and  is  never  a  counterpart.  Syph- 
ilitic eruptions  are  often  circumscribed ;  they  terminate  sud- 
denly at  their  edges,  and  do  not  gradually  shade  into  the 
sound  skin.  In  color  they  are  apt  to  be  brownish-red,  like 
tarnished  copper  ;  especially  is  this  the  case  in  late  syphilides. 
Hutchinson  cautions  us  to  remember  that  an  ordinary  non- 
specific eruption  may  be  copper-colored,  especially  in  people 
with  dark  complexion  and  when  it  occurs  on  the  legs.  Erup- 
tions are  apt  to  leave  a  brownish  stain.  Early  syphilitic  erup- 
tions are  symmetrical.  Syphilitic  eruptions  have  an  affection 
for  particular  regions,  such  as  the  forehead,  the  abdomen  and 
chest,  the  neck  and  scalp,  about  the  lips  and  the  alse  of  the 
nose,  the  navel,  anus,  groins,  between  the  toes,  and  upon  the 
palms  and  soles.  Early  secondary  eruptions  rarely  appear 
on  the  face  or  hands.  Specific  eruptions  are  polymorphous, 
various  forms  of  eruption  being  often  present  at  the  same 
time,  so  that  roseola  is  seen  here,  papules  there,  etc.  These 
syphilides  do  not  cause  as  much  itching  as  do  non-specific 
eruptions,  except  when  they  occur  upon  the  scalp,  about  the 
anus,  or  between  the  toes.  The  late  secondary  eruptions 
tend  to  an  arrangement  in  curved  lines. 

Forms  of  Bruption. — The  chief  forms  of  eruption  are 
(i)  erythema,  (2)  papular  syphilides,  (3)  pustular  syphilides, 
and  (4)  tubercular  syphilides.  Besides  these  eruptions  pig- 
mentation may  occur  (pigmentary  syphilide),  and  blood  may 
extravasate  (purpuric  syphilide). 

Prince  A.  Morrow  does  not  believe  in  erecting  the  vesicu- 
lar syphilides  into  a  special  group.     He  tells  us  that  vesicles 


SYPHILITIC  SKIX  DISEASES.  245 

sometimes  form  on  er}thematopapular  lesions,  but  their 
presence  is  an  accident  and  not  a  regular  phenomenon.  So, 
too,  the  bullous  syphilide  is  a  rare  accident  in  a  case,  and 
e\-en  when  it  occurs  soon  becomes  pustular.  The  pem- 
phigoid syphilide  is  found  almost  exclusively  in  hereditar}^ 
disease.^ 

I.  Erythema  [inacidcE,  roseola,  or  spots).  This  eruption 
usually  comes  on  gradually,  crop  after  crop  of  spots  appear- 
ing, and  many  da}'s  passing  before  an  extensive  area  is 
covered.  Occasionally,  however,  it  arises  suddenly  (after 
a  hot  bath,  after  taking  violent  exercise,  or  after  eating  an 
indigestible  meal).  This  eruption  consists  of  circumscribed 
irregularh'  round,  hyperemic  spots,  about  one-eighth  of  an 
inch  in  diameter,  whose  color  does  not  entirely  disappear  on 
pressure  in  an  old  eruption  but  does  in  a  recent  one.  The 
color  is  at  first  light  pink,  but  it  becomes  red,  purple,  or  even 
brown.  In  the  papular  form  of  erythema  the  spots  are  slightly 
elevated.  En,'thema  is  rare  upon  the  face  and  the  dorsum  of 
the  hands  and  feet.  It  attacks  especially  the  chest  and  belh', 
but  appears  often  on  the  forehead,  the  bend  of  the  elbow, 
and  the  inner  portion  of  the  thigh,  the  neck,  and  the  flexor 
surface  of  the  forearms  and  arms.  It  appears  first  on  the  ab- 
domen and  last  on  the  legs.  Usually  er}-thema  follows 
syphilitic  fever,  about  six  weeks  after  the  chancre  appears, 
and  the  number  and  distinctness  of  the  spots  are  in  propor- 
tion to  the  violence  of  the  fever.  Xo  fever  or  slight  fever 
means  there  will  be  but  few  spots  and  they  will  soon  disap- 
pear. In  rare  cases  the  eruption  is  \-er}-  transiton,^  lasting 
but  a  few  hours,  but  it  usually  continues  for  several  weeks  if 
untreated.  It  may  pass  away  or  may  be  con\"erted  into  a 
papular  eruption.  ^lercuiy  will  cause  it  to  disappear  in  a 
couple  of  weeks.  In  examining  for  this  form  of  eruption  in  a 
doubtful  case,  let  cold  air  blow  upon  the  chest  and  belly 
(Hearn) ;  this  blanches  the  sound  skin  and  makes  clear  any 
discoloration.  Xo  desquamation  attends  the  macular  erup- 
tion, but  a  brownish  stain  remains  for  a  variable  time  after 
the  eruption  fades.  Erythema  means,  as  a  rule,  a  mild  and 
curable  attack.  ^Maculae  may  be  combined  with  the  next 
form,  constituting  a  maculopapular  eruption. 

The  maculopapular  syphilides  are  evolved  from  the  macu- 
lar syphilides.  They  are  slighly  elevated,  are  situated  upon 
hyperemic  bases,  and  the  summits  of  some  of  them  may  un- 
dergo slight  desquamation.  A  roseolar  area  may  show  one 
or  several  of  these  macular  papules.     The}-  are  apt  to  arrange 

^  Morrow's  System  of  Genito-iirinary  Diseases,  Syphilology,  and  Dermatology. 


246  SYPHILIS. 

themselves  in  segments  of  a  circle,  and  are  symmetrically 
distributed.  This  eruption  usually  appears  early,  but  may 
appear  late.  It  may  fade  and  reappear  several  times  in  the 
same  patient.     The  eruption  lasts  a  few  weeks. 

2.  Papular  syphilides,  which  are  papules  or  elevations 
covered  with  dry  skin,  may  or  may  not  desquamate.  If  they 
do  desquamate,  the  process  begins  over  the  center.  They 
usually  appear  from  the  third  to  the  sixth  month  of  the  dis- 
ease. They  may  be  preceded  by  fever,  and  often  reappear 
again  and  again.  They  are  at  first  red,  but  become  brownish. 
They  are  firm  in  feel  and  vary  in  size  from  the  head  of  a  pin 
to  a  five-cent  piece  or  larger.  They  may  be  present  as 
miliary  papules,  lenticular  papules,  papules  which  scale  off 
(papulosquamous  eruption),  and  moist  papules.  Papules  on 
fading  leave  coppery-looking  stains.  Papules  upon  the  palms 
and  soles  constitute  the  so-called  "  palmar  and  plantar  psori- 
asis," which  appears  from  three  months  to  one  year  after  the 
appearance  of  the  chancre.  Papules  just  below  the  line  of 
the  hair  on  the  forehead  constitute  the  corona  venerea.  Papu- 
lar syphilides  appear  especially  upon  the  forehead,  the  neck, 
the  abdomen,  and  the  extremities.  The  papular  or  squamous 
syphilide  of  the  palms  and  soles  begins  as  a  red  spot  which 
becomes  elevated  and  brownish ;  the  epidermis  thickens  and 
is  cast  off,  and  there  then  remains  a  central  red  spot  sur- 
rounded by  undermined  skin.  If  papules  are  in  regions 
where  they  are  kept  moist  (as  about  the  anus),  they  become 
covered  with  a  sodden  gray  film  which  after  a  time  is  cast  off 
and  leaves  the  papule  without  epidermis.  The  sodden  papules 
are  called  "  flat  condylomata,"  moist  or  humid  papules  or 
plates.  Papules  which  are  at  first  small  may  become  large. 
The  small  or  miliary  papules  constitute  syphilitic  lichen.  The 
lenticular  papules  are  most  common,  and  strongly  tend  to 
scale  off.  The  papular  syphilides  give  a  worse  prognosis  for 
the  constitutional  disease  than  do  spots. 

3.  Pustular  syphilides  arise  from  papules.  The  condition 
is  known  as  acne  when  the  apex  of  a  papule  softens,  impetigo 
when  the  whole  papule  suppurates,  and  ecthyma  or  rupia 
when  the  corium  is  also  deeply  involved.  Vesicles  occasionally 
precede  pustules.  The  pustular  eruption  appears  a  number  of 
months  after  infection  and  later  than  the  papular.  The  pus- 
tular eruption  gives  a  very  bad  prognosis  for  the  constitu- 
tional disease.  Rupia  is  formed  by  a  pustule  rupturing  or  a 
papule  ulcerating,  the  secretion  diying  and  forming  a  conical 
crust  which  continually  increases  in  height  and  diameter, 
while  the  ulceration  extends  at  the  edges.     When  the  crust 


AFFECTIONS   OF   THE   MUCOUS  MEMBRANES.        247 

is  pulled  off  there  is  seen  a  foul  ulcer  with  congested,  ja<^ged, 
and  undermined  edges.  Rupia  may  be  secondary  or  tertiary, 
and  it  invariably  leaves  scars.  It  appears  only  after  at  least 
six  months  have  passed  since  the  chancre  began.  Secondary 
rupia  is  symmetrical.     Tertiary^  rupia  is  asymmetrical. 

4.  Tubercular  syphilides  are  greatly  enlarged  papules 
intermediate  between  ordinary  papules  and  gummata. 

Diagnosis  bctivccii  Secondary  and  Tertiary  Syphilides. — A 
secondary  eruption  is  distinguished  from  a  tertiary  eruption 
by  the  following :  the  first  tends  to  disappear,  the  second 
tends  to  persist  and  to  spread ;  the  first  is  general  and  sym- 
metrical, the  second  is  local  and  asymmetrical ;  the  first  does 
not  spread  at  its  edge,  the  second  tends  to  spread  at  its  edge, 
and  this  tendency,  which  is  designated  "  serpiginous,"  pro- 
duces an  ulcer  shaped  like  a  horseshoe  (Jonathan  Hutchin- 
son). Secondary  lesions  appear  within  certain  limits  of  time, 
develop  regularly,  and  are  dispersed  by  mercurial  treatment. 
Tertiary  lesions  appear  at  no  fixed  time,  develop  irregularly, 
and  are  not  cleared  up  by  mercury. 

Affections  of  the  Mucous  Membranes. — The  chief 
lesions  in  syphilitic  affections  of  the  mucous  membranes  are 
mucous  patches,  warts,  and  condylomata.  The  first  phe- 
nomena of  secondary  syphilis  are,  as  a  rule,  symmetrical 
ulcers  of  the  tonsils,  painless,  of  temporary  duration,  and 
superficial  (Hutchinson).  The  borders  of  the  ulcers  are 
gray,  and  the  areas  are  reniform  in  shape.  Catarrhal  inflam- 
mations often  occur.  Eruptions  appear  on  the  mucous  mem- 
branes as  upon  the  skin.  Mucous  patches  are  papules  de- 
prived of  epithelium  ;  they  are  gray  in  color,  are  moist,  and 
give  off"  an  offensive  and  virulent  discharge.  They  usually 
appear  as  areas  of  congestion,  swelling,  and  abrasion  of  the 
epidermis  upon  the  lips,  palate,  gums,  tongue,  cheeks,  vagina, 
labia,  vulva,  scrotum,  anus,  and  under  the  prepuce.  A  moist 
papule  of  the  skin  is  really  a  mucous  patch.  These  patches, 
which  are  always  circular  or  oval,  are  among  the  most  con- 
stant lesions  of  the  secondary  stage,  appearing  from  time  to 
time  during  many  months.  If  a  patch  has  the  papillae  de- 
stroyed, it  is  called  a  "  bald  patch."  If  the  papules  present 
hypertrophied  papillae  fused  together,  there  appear  enlarge- 
ments with  flat  tops,  termed  '*  condylomata  ;"  if  the  papillae 
of  the  papules  hypertrophy  and  do  not  fuse,  the  growths  are 
called  "warts."  Mucous  lesions  of  the  mouth  are  commonest 
in  smokers  and  in  those  with  bad  or  neglected  teeth.  Hutchin- 
son says  that  persistence  in  smoking  during  syphilis  may  cause 
leukomata,  or  persistent  white  patches.     The  vagina  and  lips 


248  SYPHILIS. 

of  the  vulva  during  the  secondary  stage  are  often  covered 
with  mucous  patches.  The  uterus  may  contain  mucous 
lesions  which  poison  the  uterine  discharge.  The  larynx  may 
suffer  from  inflammation,  eruptions,  and  ulceration  (hence 
the  hoarse  voice  which  is  so  usual).  The  nasal  mucous 
membrane  may  also  suffer.  The  rectal  mucous  membrane 
may  be  attacked  with  patches,  and  so  may  the  glans  penis, 
the  inner  surface  of  the  prepuce,  and  the  urethra..  Early  in 
the  secondary  stage  in  some  cases  there  is  a  slight  muco- 
purulent urethral  discharge,  and  examination  with  an  en- 
doscope shows  redness  of  the  mucous  membrane  of  the 
anterior  urethra.  The  discharge  is  contagious.  The  con- 
dition may  be  followed  by  constriction  of  the  urethral  cali- 
ber.    Distinct  ulceration  may  take  place. 

Affections  of  the  Hair. — In  syphilis  the  hair  is  usually 
shed  to  a  great  extent.  This  loss  may  be  widespread  (beard, 
mustache,  head,  eyebrows,  pubic  hair,  etc.)  or  it  may  be  lim- 
ited. Complete  baldness  sometimes  ensues,  but  it  is  rarely 
permanent.  The  hairs  of  the  head  are  first  noticed  to  come 
out  on  the  comb  ;  on  pulling  them  they  are  found  loose  in 
their  sheaths — so  loose  that  Ricord  has  said  "  a  man  would 
drown  if  a  rescuer  could  pull  only  upon  the  hair  of  the 
head."  The  falling  out  of  the  hair,  which  is  known  as 
"  alopecia,"  usually  begins  soon  after  the  fever  or  about  the 
time  of  the  eruption,  but  it  may  be  postponed  much  later. 
The  skin  of  a  syphilitic  bald  spot  is  never  smooth,  but  is 
scaly.  The  hair  may  thin  generally,  baldness  may  appear 
in  twisting  lines,  or  it  may  be  complete  only  in  limited  areas. 
Alopecia  results  from  shrinking  of  the  hair-pulp,  death  of  the 
hair,  and  casting  off  of  the  sheath. 

Affections  of  the  Nails. — Paronychia  is  inflammation 
and  ulceration  of  the  skin  in  contact  with  a  nail  and  extend- 
ing to  the  matrix.  The  nail  is  cast  off  partially  or  entirely. 
Onychia  is  inflammation  of  the  matrix,  and  is  manifested  by 
white  spots,  brittleness  or  extended  opacity,  twisting,  and 
breaking  off  of  the  nail.  The  parts  around  are  not  affected. 
The  damaged  nail  drops  off  and  another  diseased  nail 
appears. 

Affections  of  the  Bar. — Temporary  impairment  of 
hearing  in  one  or  both  ears  is  not  uncommon  in  syphilitic 
affections  of  the  ear.  Rarely,  permanent  symmetrical  deaf- 
ness is  produced.  Meniere's  disease  is  sometimes  caused  by 
syphilis. 

Affections  of  the  Bones  and  Joints. — In  syphilis 
there   may  be   slight    and    temporaiy  periostitis.     Pain  and 


INTERMEDIATE   PERIOD.  249 

tenderness  arise  in  various  bones,  the  pain  being  worse  at 
night  (osteocopic  pains).  Osteoperiostitis  usually  arises  with 
or  after  the  onset  of  the  secondary  eruption,  but  in  rare  in- 
stances precedes  the  syphilides.  The  bones  usually  involved 
are  the  tibise,  clavicles,  and  skull.  Intense  headache  may  be 
due  to  periostitis  of  the  inner  surface  of  a  cranial  bone 
(Mauriac).  Local  periostitis  may  form  a  soft  node  which  by 
ossification  becomes  a  hard  node.  Pain  like  that  of  rheu- 
matism affects  the  joints.  Symmetrical  synovitis  has  been 
noted.  Secondary  syphilitic  disease  of  bone,  periosteum,  and 
joints  lasts  only  a  short  time  and  is  never  destructive. 

Affections  of  the  !Bye. — Iritis  is  the  commonest  eye 
trouble  which  may  arise  during  secondary  syphilis.  It  appears 
from  three  to  six  months  after  the  chancre,  and  begins  in  one 
eye,  the  other  eye  soon  becoming  affected.  The  symptoms 
are  a  pink  zone  in  the  sclerotic,  a  congested,  red  or  muddy 
iris,  irregularity  of  the  pupil  accentuated  by  atropin,  the 
existence  of  pain  and  photophobia,  and  sometimes  hazy  or 
even  clouded  pupil.  Rheumatic  iritis  causes  much  pain  and 
photophobia,  syphilitic  iritis  comparatively  little  ;  there  is  less 
swelling  in  the  first  than  in  the  second  ;  the  former  tends  to 
recur,  the  latter  does  not.  Iritis  is  usually  recovered  from, 
good  vision  being  retained.  Diffuse  retinitis  and  disseminated 
choroiditis  never  occur  until  a  number  of  months  have  passed 
since  the  infection.  The  symptoms  are  failure  of  sight,  muscae 
volitantes,  and  very  little  photophobia.  The  diagnosis  of 
retinitis  and  choroiditis  is  made  by  the  ophthalmoscope. 

Affections  of  the  Testes. — Syphilitic  Sarcocele. — 
The  testicle  enlarges  because  of  plastic  inflammation.  Both 
glands  usually  suffer,  but  not  always.  Fluid  distends  the  tunica 
vaginalis.  The  epididymis  escapes.  The  testicle  is  not  the 
seat  of  pain,  is  troublesome  because  of  its  weight,  and  has 
very  little  of  the  proper  sensation  on  squeezing.  The  plastic 
exudate  is  generally  largely  absorbed,  but  it  may  organize 
into  fibrous  tissue,  the  organ  passing  into  atrophic  cirrhosis. 

Intermediate  Period. — Secondary  lesions  cease  to 
appear  in  from  eighteen  months  to  three  years.  In  the 
intermediate  period  no  symptoms  may  appear,  but  the  dis- 
ease is  still  for  some  time  latent  and  is  not  cured.  Symptoms 
may  appear  from  time  to  time.  These  symptoms,  which  are 
called  "  reminders,"  are  not  so  severe  as  tertiary  symptoms  ; 
are  apt  to  be  symmetrical,  and  do  not  closely  resemble  secon- 
dary lesions.  Among  the  reminders  we  may  name  palmar 
psoriasis  and  sarcocele.  Sarcocele  in  this  stage  is  bilateral 
and  rarely  painful.    Bilateral  indolent  epididymitis  occasionally 


250  SYPHILIS. 

occurs.  Sores  on  the  tongue,  a  papular  skin-eruption,  and 
choroiditis  may  arise.  Gummata  occasionally  occur  in  this 
stage,  but  they  are  apt  to  be  symmetrical  and  non-persistent. 
Arteritis  may  occur,  beginning  in  the  intima  oradventitia.and 
causing,  it  may  be,  aneurysm,  thrombosis,  or  embolism. 
Obliterative  endarteritis  may  cause  gangrene.  Vascular 
changes  are  notably  common  in  the  vessels  of  the  brain,  and 
thrombosis  may  occur,  in  which  case  a  paralysis  comes  on 
gradually,  preceded  by  numbness,  although  sudden  paralysis 
may  take  place.  These  paralyses  may  be  limited,  extensive, 
transitor}^,  or  permanent.  The  nervous  system  often  suffers 
in  this  stage  (anesthetic  areas  and  retinitis).  The  viscera  are 
often  congested  and  infiltrated  (tonsils,  liver,  spleen,  kidneys, 
and  lungs). 

Tertiary  Syphilis. — This  stage  is  not  often  reached,  the 
disease  being  cured  before  it  has  been  attained.  It  is  not 
so  much  a  stage  of  syphilis  as  a  condition  of  impaired  nutri- 
tion which  results  from  the  disease.  This  view  finds  con- 
firmation in  the  fact  that  tertiary  lesions  do  not  furnish  the 
contagion.  The  primary  stage  disappears  without  treatment, 
the  secondary  stage  tends  ultimately  to  spontaneous  disap- 
pearance, but  tertiary  lesions  tend  to  persist  and  to  recur. 
Tertiary  lesions  may  be  single  or  may  be  widely  scattered  ; 
when  multiple  they  are  not  symmetrical  except  by  accident. 
These  lesions  may  attack  any  tissue,  even  after  many  years 
of  apparent  cure  ;  they  all  tend  to  spread  locally,  they  all 
leave  permanent  atrophy  or  thickening,  they  all  tend  to 
relapse,  and  a   local  influence  is  often  an  exciting  cause. 

Tertiary  skin-eruptions  are  liable  to  ulcerate.  Various 
eruptions  may  occur:  papular  syphilides,  pustular  syphilides, 
gummatous  syphilides,  serpiginous  syphilides,  and  pigmentary 
syphilides.  The  characteristic  syphilide  is  rupia,  which  is 
formed  by  a  pustule  rupturing  or  a  papule  ulcerating.  A 
brown  or  black  crust  forms  because  of  the  drying  of  the  dis- 
charee,  ulceration  continues  under  the  crust,  new  crusts  form, 
and,  as  the  ulcer  is  constantly  increasing  peripherally,  the 
new  crusts  are  larger  in  diameter  than  the  old  ones,  and  the 
mass  assumes  the  form  of  a  cone.  An  ulcer  Avhich  has 
destroyed  the  deeper  layers  of  the  skin  is  exposed  by  tearing 
off  the  crust.  On  healing  the  rupial  ulcers  always  leave  a 
permanent  scar. 

Serpig-inous  ulcers  are  common  in  tertiary  syphilis,  and 
are  especially  common  about  the  knees,  nostrils,  forehead,  and 
lips.  Serpiginous  ulceration  is  spoken  of  as  syphilitic  lupus. 
It  is  preceded  by  a  widespread,  brown-colored  nodular  cuta- 


TER  TIA  R  Y  S  YPHIL  IS.  2  5  I 

neous  infiltration.  The  nodules  suppurate,  run  together, 
crust,  and  produce  an  ulcer  which  spreads  rapidly  and  becomes 
the  shape  of  a  horseshoe. 

The  Gumma. — The  gumma  is  the  typical  tertiary  lesion. 
A  gumma  arises  from  an  inflammation  the  products  of  which 
are  unable  to  organize  for  want  of  sufficient  blood-supply, 
and  consequently  undergo  fatty  degeneration.  A  gumma 
presents  a  center  of  gummy  degeneration,  a  surrounding  area 
of  immature  fibrous  tissue,  and  an  outer  zone  of  embryonic 
tissue  and  leukocytes.  A  gumma,  when  it  is  spontaneously 
evacuated,  exhibits  a  small  opening  or  many  openings  with 
very  thin  red  and  undermined  edges  ;  the  ulcer  is  slow  to 
heal,  and  forms  a  thin  scar,  white  in  the  center,  but  pig- 
mented at  the  margins  and  usually  depressed  (Jonathan 
Hutchinson,  Jr.).  The  gummatous  ulcer  is  deep,  circular  in 
•outline,  with  undermined  edges  and  an  uneven  floor  covered 
with  a  thick  white  adherent  slough.  Sometimes  there  is  no 
slough,  but  an  extensive  area  is  infiltrated.  A  gummatous 
ulcer  may  coalesce  with  one  or  m.ore  adjacent  ulcers.  The 
discharge  is  scanty  and  tenacious.  These  ulcers  are  often 
seen  upon  the  legs,  and  when  once  healed  rarely  recur. 
A  gumma  in  the  internal  organs  may  become  a  fibrous  mass. 
Gummata  form  in  the  skin,  subcutaneous  tissues,  muscles, 
tongue,  joints,  bursae,  testes,  spinal  cord,  brain,  and  internal 
organs.  In  tertiary  syphilis  an  inflammation  may  not  form 
a  circumscribed  gumma,  but,  in  stead,  may  produce  a  diffuse 
degenerating  mass.  This  type  of  inflammation,  which  is  seen 
in  bones,  is  called  "  gummatous."  A  healing  gumma  in  a 
mucous  canal  such  as  the  rectum  or  larynx  causes  thickening 
and  stricture.  Tertiary  syphilis  is  a  common  cause  of  amy- 
loid degeneration  and  the  most  frequent  cause  of  arterial  and 
nervous  sclerosis. 

Various  Lesions. — Hutchinson  enumerates  the  lesions  of 
tertiary  syphilis  as  follows  :  Periostitis,  forming  nodes  or  caus- 
ing sclerotic  hypertropy  or  suppuration  or  necrosis  ;  gum- 
mata in  various  parts ;  disease  of  the  skin  of  the  type  of 
rupia  or  lupus  ;  gumma  or  inflammation  of  the  tongue,  causing 
sclerosis  ;  structural  changes  in  the  nervous  s}'stem,  causing 
ataxia,  ophthalmoplegia  externa  and  interna,  general  paresis, 
optic  atrophy,  and  paralyses  of  cerebral  nerves ;  amyloid 
degenerations  ;  and  chronic  inflammation  of  certain  mucous 
membranes  (of  the  mouth,  pharynx,  vagina,  rectum,  etc.), 
with  thickening  and  ulceration.  Gummatous  osteoperiostitis 
of  the  vertebrse  may  arise,  and  this  may  be  associated  with 
disease  of  the  membranes  or  cord.  Syphilitic  inflammation  of 


252  SYPHILIS. 

vertebrae  is  called  syphilitic  spondylitis.  Unilateral  enlarge- 
ment of  the  epididymis  is  sometimes  noted,  the  mass  feeling 
heavy,  aching  a  little,  but  not  being  very  tender.  Unilateral 
sarcocele  may  be  met  with. 

Visceral  Syphilis. — In  visceral  syphilis  the  lungs  may 
undergo  fibroid  induration  (syphilitic  phthisis).  Syphilitic 
phthisis  is  a  nonfebrile  malady.  Gummata  may  form  in  the 
heart,  liver,  spleen,  or  kidneys.  The  capsule  and  fibrous  septa 
of  the  liver  may  thicken,  the  organ  being  puckered  by  con- 
traction. Amyloid  changes  may  appear  in  any  of  the  viscera. 
Albuminuria  may  occur  in  tertiary  syphilis.  It  may  be 
caused  by  fibroid  changes  in  the  kidneys,  by  the  formation 
of  gummata,  or  by  amyloid  degeneration.  Its  occurrence 
should  be  watched  for.  Mercury  and  iodid  of  potassium 
have  been  regarded  as  causative  of  albuminuria  in  some  cases. 

Syphilis  may  cause  disease  of  the  stomach,  and  probably 
does  so  more  frequently  than  was  formerly  supposed,  because 
it  is  difficult  to  distinguish  from  more  common  diseases.  The 
condition  may  be  gummatous  infiltration  of  the  walls  of  the 
stomach,  multiple  and  minute  gummata,  ulcerations  resulting 
from  breaking  down  of  gummata,  or  syphilitic  endarteritis 
of  the  gastric  vessels.  When  ulcers  heal  cicatricial  contrac- 
tion results.  Syphilitic  ulcers  and  gummata  may  be  cured 
by  efficient  antisyphilitic  treatment.  Like  lesions  may  form 
in  the  intestines. 

Flexner,  Mracek,  Frankel,  Fournier,  and  others  have  dis- 
cussed this  subject.^ 

Nervous  syphilis  may  be  manifested  in  disorders  of  the 
brain,  cord,  or  nerves.  Brain  syphilis  is  usually  a  late  phe- 
nomenon (from  one  to  thirty  years  after  infection),  and  is  more 
apt  to  appear  after  light  than  after  severe  secondaries.  The 
lesion  maybe  gumma  of  the  membranes  (tumor),  gummatous 
meningitis,  arterial  atheroma,  or  obliterative  endarteritis.  A 
gumma  may  eventuate  in  a  scar,  a  cyst,  or  a  calcareous  mass. 
The  symptoms  of  brain  syphilis  depend  on  the  nature,  seat, 
and  rate  of  development  of  the  lesions.  It  is  to  be  noted 
that  syphilitic  palsy  is  apt  to  be  limited,  progressive,  and 
incomplete.  Epilepsy  appearing  after  the  thirtieth  year  is 
very  probably  specific  if  alcohol  as  a  cause  can  be  ruled 
out  (Wood).  Persistent  headache,  tremor,  insomnia  or  som- 
nolence, transitory,  limited,  and  erratic  palsies,  unnatural 
slowness  of  utterance,  amnesia,  vertigo,  and  epilepsy  are 
very  suggestive  of  syphilis.  Sudden  ptosis  is  very  significant ; 
so  is  sudden  palsy  of  one  or  more  of  the  extrinsic  eye-muscles. 

^  See  editorial  \x\  Joicr.  Amer.  Med.  Assoc,  Marcli  24,  1900. 


TREATMENT   OF  PRIMARY  STAGE.  253 

In  SN'philitic  insomnia  the  patient  cannot  get  to  sleep  at  night 
for  a  long  while,  but  when  he  once  gets  to  sleep  he  reposes 
well.  The  type  of  insanity  which  is  most  apt  to  arise  is  a 
likeness  or  counterpart  of  general  paralysis,  and,  like  ordinary 
paresis,  it  is  not  curable.  Spinal  syphilis  may  cause  sclerosis, 
a  condition  like  Landry's  paralysis,  softening,  and  tumor. 
Neuritis  is  not  uncommon  in  syphilis.  Many  of  the  lesions 
which  follow  syphilis  are  due  to  it  only  indirectly,  and  are 
not  benefited  by  specific  treatment.  W'e  speak  of  such  con- 
ditions as  parasyphilitic  diseases.  Among  them  are  paresis 
and  locomotor  ataxia. 

Justus's  Test  for  SypMlis. — The  test  consists  in  first 
estimating  the  amount  of  hemoglobin  present,  then  making  a 
single  mercurial  inunction,  and  again  estimating  the  hemo- 
globin. It  is  claimed  that  the  corpuscles  of  an  untreated 
syphilitic  are  unduly  sensitive,  and  if  the  disease  is  present  a 
mercurial  inunction  will  cause  a  loss  of  10  to  20  per  cent,  of 
hemoglobin,  which  fall  persists  for  a  few  hours.  The  absolute 
value  of  this  test  is  somewhat  doubtful.  It  is  often  demon- 
strable in  secondar}%  tertiary,  or  congenital  syphilis.  This  test 
usually  fails  in  latent  cases  and  in  early  secondary  syphilis.^ 

Treatment  of  Primary  Stage. — \  chancre  should  not 
be  excised.  The  disease  is  constitutional  when  the  chancre 
appears,  and  excision  and  cauterization  inflict  needless  pain 
and  do  no  good.  The  initial  lesion  should  never  be  cauter- 
ized unless  it  is  phagedenic  or  becoming  so.  Order  the  patient 
to  soak  the  penis  for  five  minutes  twice  daily  in  warm  salt 
water  (a  teaspoonful  of  salt  to  a  cupful  of  water),  and  then 
to  spray  the  sore  with  peroxid  of  hydrogen  (14-volume  solu- 
tion of  peroxid  diluted  with  an  equal  bulk  of  water)  from  an 
atomizer.  The  ulcer  is  then  dried  with  absorbent  cotton 
and  on  it  is  dusted  a  powder  composed  of  equal  parts  of  bis- 
muth and  calomel.  The  buboes  in  the  groin  require  no  local 
treatment  unless  they  tend  to  suppurate.  If  they  persist  or 
become  large,  paint  them  with  iodin  or  rub  ichthyol  oint- 
ment or  mercurial  ointment  into  them,  and  apply  a  spica 
bandage  of  the  groin.  Some  authorities  give  mercur}^  in  this 
stage,  in  order  to  prevent  secondaries.  The  younger  Gross 
opposed  this  strongly,  and  affirmed  a  wish  to  see  the  sec- 
ondary eruption — first,  because  it  proves  the  diagnosis  ;  and, 
second,  because  it  affords  valuable  prognostic  indications  (an 
er}'thematous  eruption  means  a  light  case ;  an  early  pustular 
eruption  means  a  grave  case  with  serious  complications).  I 
have    always   followed   the  plan  of  Gross,  and  do  not  order 

1  D.  H.  Jones,  N.    V.  Med.  Jour.,  April  7,  1900. 


254  SYPHILIS. 

mercury  until  constitutional  symptoms  develop.  If  phage- 
dena arises,  place  the  patient  at  once  upon  stimulants  and 
nutritious  diet,  secure  sleep,  and  destroy  the  ulcer  by  the  use 
of  nitric  acid  or  the  electric  cauter}^  while  the  patient  is 
anesthetized.  After  cauterization  with  iodoform,  dress  with  wet 
antiseptic  gauze.  Several  times  a  day  change  the  dressings, 
and  at  each  change  spray  wdth  peroxid  of  hydrogen,  irrigate 
w^ith  bichlorid  of  mercury  solution,  and  dust  with  iodoform. 
It  may  be  necessary  to  cauterize  several  times.  In  some 
cases  it  will  be  necessary  to  employ  continuous  irrigation  with 
an  antiseptic  fluid.  These  cases  are  sometimes  fatal  and 
usually  produce  great  destruction  of  tissue.  In  chancre  redux 
w^atch  carefully  for  the  development  of  symptoms,  in  order 
to  determine  if  the  condition  is  really  one  of  reinfection  or 
if  we  are  dealing  with  a  gumma  which  resembles  a  chancre 
in  appearance. 

Treatment  of  Secondary  Stage. — In  the  secondar}- 
stage  the  aim  is  to  cure  the  disease.  That  it  can  be  cured 
is  known  from  the  fact  that  reinfection  occurs  in  some 
persons.  The  old  axiom,  "  SyphiHs  once,  syphilis  ever,"  is 
not  true.  IMercury  must  be  used,  the  form  being  a  matter 
of  choice.  Fournier  first  advocated  intermittent  treatment. 
In  this  plan  give  gr.  \  of  protiodid  of  mercury  daily  for  six 
months,  then  stop  a  month ;  then  give  mercury  for  three 
months,  then  stop  two  months.  During  the  first  year  the 
patient  is  under  treatment  nine  months,  and  during  the 
second  year  eight  months.  Some  prefer  the  intermittent 
and  others  the  continuous  plan  of  treatment.  In  following 
the  continuous  plan  find  the  patient's  tolerance  to  mercur}^ 
and  keep  him  for  two  years  on  daily  doses  below  the  amount 
he  will  tolerate.  Gross's  rule  for  continuous  treatment  was  to 
order  pills  of  the  green  iodid  of  mercur\%  each  pill  containing 
gr.  i.  The  patient  was  ordered  one  pill  after  each  meal  to 
begin  with  ;  the  next  day  the  after-breakfast  dose  was  in- 
creased to  two  pills  ;  the  following  day  the  after-dinner  dose 
was  two  pills,  and  so  on,  one  pill  being  added  ever\'  day. 
This  advance  was  continued  until  there  was  slight  diarrhea, 
griping,  a  metallic  taste,  or  tenderness  on  snapping  the 
teeth  together,  w^hereupon  one  pill  was  taken  off  each  day 
until  all  unfavorable  symptoms  disappeared.  This  experi- 
mentation finds  a  dose  on  which  the  patient  can  be  kept 
with  entire  safet}^  for  a  long  time  ;  but  if  it  is  found  that  colic 
or  diarrhea  is  apt  to  recur,  there  must  be  added  to  each  pill 
gr.  ^  of  opium.  The  patient  is  given  mercur>'  in  this  way 
for  two  years.     Ever}-  time  new  symptoms  appear  the  dose 


TREATMENT   OE  SECONDARY  STAGE.  255 

is  raised,  and  as  soon  as  they  disappear  it  is  lowered  to  the 
standard.    If  the  protiodid  is  not  tolerated,  give  the  bichlorid  : 

U.    Hydraig.  chlor.  corros. ,  gf- j ; 

Syr.  sarsaparilla;  comp. ,  fo''J- — ^^• 

Sig.  f  3,  in  water,  after  meals. 

Mercuiy  with  chalk  in  i-  or  2-grain  doses  four  times  a  day,  with 
or  without  Dover's  powder  in  i-grain  doses,  may  be  used. 
Mercurial  inunctions  produce  a  rapid  effect,  but  irritate  the 
skin.  The  drug  should  be  rubbed  in  with  a  gloved  hand. 
There  can  be  used  once  a  day  \  dram  of  oleate  of  mercury 
(10  per  cent.)  or  i  dram  of  mercurial  ointment,  rubbed  into 
the  skin.  The  first  day  it  is  rubbed  into  the  inside  of  one 
thigh,  the  second  day  into  the  inside  of  the  other  thigh ;  the 
third  day  into  the  inside  of  one  arm  ;  the  fourth  day  into 
the  other  arm ;  next,  into  one  groin  and  then  into  the  other 
groin,  and  then  inunction  is  again  made  at  the  point  of 
original  application,  and  so  on.  After  the  rubbing  the 
patient  puts  on  underclothes  and  goes  to  bed,  and  in  the 
morning  takes  a  bath.  The  ointment  may  be  smeared  on  a 
rag,  which  is  then  worn  between  the  stocking  and  sole  of  the 
foot  during  the  day. 

Fumigation  is  performed  by  volatiHzing  each  night  3j  of 
calomel.  The  patient  sits  naked  on  a  cane-seat  chair,  and 
is  wrapped  up  to  the  neck  in  a  blanket  which  drops  tent- 
like to  the  floor ;  the  calomel  is  put  upon  an  iron  plate  under 
the  chair,  and  is  heated  by  an  alcohol  lamp  beneath  the 
plate.  The  skin  becomes  coated  with  calomel,  and  the  sub- 
ject, after  putting  on  woollen  drawers  and  an' undershirt, 
gets  into  bed.  Hypodermatic  injections  of  mercury  are  used 
by  some  physicians.  They  cause  an  eruption  to  disappear 
rapidly,  but  may  produce  abscesses,  and  relapses  are  prone 
to  occur.  Orville  Horwitz  has  recently  made  thorough  trial 
of  the  hypodermatic  method,  and  arrives  at  the  following 
conclusions  :  it  will  not  abort  the  disease ;  it  should  never 
be  a  routine  treatment ;  in  suitable  cases  it  is  very  valuable 
for  symptomatic  use,  as  when  lesions  on  the  face  or  in  im- 
portant structures  make  a  rapid  impression  desirable  or  neces- 
sary ;  in  cases  which  obstinately  relapse  under  other  treatment, 
and  in  syphilis  of  the  nervous  system.  J.  William  White, 
after  a  large  experience  with  this  method,  says  that  hypo- 
dermatic injections  of  corrosive  sublimate  are  painful  and 
are  strongly  objected  to  by  many  patients ;  that  this  method 
of  treatment  is  occasionally  dangerous  and  even  fatal ;  that 
it  is  liable  to  be  followed  by  local  complications  (erythema. 


256  SYPHILIS. 

nodosities,  cellulitis,  abscess,  sloughing) ;  that  it  cannot  be 
carried  out  by  the  patient,  but  requires  the  surgeon's  con- 
stant intervention.  This  syphilographer  concludes  that  hypo- 
dermatic medication  does  not  offer  advantages  justifying  its 
use  as  a  systematic  method  of  treatment,  and  that  it  encour- 
ages insufficient  treatment — those  "  short  heroic  courses  " 
which  Hutchinson  shows  are  followed  by  the  gravest  tertiary 
lesions.  "  The  claim  that  by  a  few  injections  the  time  of 
treatment  can  be  measured  by  months  or  even  by  weeks, 
instead  of  by  years,  would  seem,  as  Mauriac  has  said,  to 
involve  the  idea  that  mercury  given  hypodermatically  acquires 
some  new  and  pow'erful  curative  property  which,  given  in 
other  ways,  it  does  not  possess."^  The  usual  plan  is  to  give 
daily  a  hypodermatic  injection  of  corrosive  sublimate  deep 
into  the  back  or  buttock,  the  dose  being  gr.  \  of  the  drug. 
Thirty  such  injections  are  used  unless  some  contraindication 
demands  their  discontinuance  sooner.  The  treatment  is  then 
stopped.  If  the  symptoms  recur,  however,  the  patient  is 
given  another  course,  the  daily  dosage  being  gr.  \,  the 
treatment  being  again  stopped  after  thirty  injections,  but 
continued  anew  in  |-grain  doses  if  the  symptoms  recur. 
The  use  of  gray  oil  hypodermatically  has  warm  advocates. 
It  is  claimed  that  it  provokes  but  little  pain  and  irritation,  and 
that  it  is  a  very  efficient  remedy.  The  oil  must  be  warmed 
and  shaken  before  being  used.  Lang  injects  gr.  f  to  gr.  i^ 
of  the  50  per  cent,  gray  oil,  or  twice  this  quantity  of  the  30 
per  cent,  oil,  twice  during  the  first  w^eek,  once  during  the 
second  week,  and  after  this  once  a  week  or  once  every  other 
week  for  an  indefinite  period  of  time.  It  may  be  given  oftener 
if  symptoms  arise  or  persist. 

Taylor  believes  that  gray  oil  may  give  rise  to  unpleasant 
and  sometimes  even  to  dangerous  symptoms,  and  it  should  be 
used  with  extreme  care  and  only  in  selected  cases  in  which 
other  remedies  are  contraindicated.  He  says  that  in  reading 
about  the  hypodermatic  method  he  has  been  struck  with  the 
fact  that  "  the  most  serious  results  have  almost  invariably 
followed  injections  in  which  fatty  matters  have  been  the 
vehicle  of  suspension."  ^ 

Some  surgeons  employ  intravenous  injections  of  mercury. 
Lane  injects,  at  first  every  other  day  and  later  daily,  20in  of 
a  I  per  cent,  solution  of  cyanid  of  mercury.  The  skin  in 
front  of  the  elbow  is  rendered  aseptic,  a  fillet  is  tied  around 

1  J.  V\'illiam  White,  in  Morrow's  System  of  Ge7iito-urinary  Diseases,  Syph- 
ilology,  and  Dermatology. 

2  Venereal  Diseases,  by  Robert  W.  Taylor. 


ACUTE   PTYALISM,    OR   SALIVATION:  257 

the  arm,  the  needle  is  inserted  into  a  vein,  the  fillet  is  loosened, 
the  fluid  is  injected,  and  the  needle  is  withdrawn.  This 
method  of  using  mercury  is  painless  and  produces  a  rapid 
effect.  It  may  be  used  in  nervous  syphilis,  but  should  not 
be  used  as  a  routine.  In  whatever  way  mercury  is  given,  do 
not  allow  it  to  produce  salivation  (hydrargyrism  or  ptyalism). 
Always  remember  that  mercury  may  cause  albuminuria  and 
examine  the  urine  at  regular  intervals  during  a  course  of  the 
drug.  If  albumin  appears  in  the  urine,  cut  down  the  dose  of 
mercury  or  stop  the  drug  for  a  time.  In  the  beginning  of  a 
case  of  syphilis,  if  the  kidneys  are  found  to  be  diseased,  give 
the  mercuiy  cautiously,  and  never  fail  to  examine  the  urine 
at  regular  intervals. 

Acute  Ptyalism,  or  Salivation. — In  acute  ptyalism  the 
saliva  becomes  thick  and  excessive  in  amount ;  the  gums  be- 
come tender  (found  first  by  snapping  the  teeth),  spongy,  and 
tend  to  bleed ;  a  metaUic  taste  is  complained  of;  the  breath 
becomes  fetid  ;  the  oral  structures  swell;  the  teeth  loosen; 
the  saliva  is  produced  in  great  quantity  ;  and  there  are  purging, 
colic,  and  exhaustion.  Sometimes  there  are  fever  and  a  diffuse 
scarlatiniform  eruption  upon  the  skin.  A  chronic  hydrargy- 
rism may  be  shown  by  salivation,  gastro-intestinal  disorder, 
emaciation,  mental  depression,  weakness,  albuminuria,  and 
tremor.  To  avoid  salivation,  advance  the  dose  with  great 
caution  and  instruct  the  patient  as  to  the  first  signs  of  the 
trouble.  He  should  use  a  soft  tooth-brush  and  an  astringent 
mouth-wash  (gr.  xlviij  of  boric  acid  to  giv  each  of  Listerine 
and  water).  When  ptyalism  is  noted,  discontinue  the  admin- 
istration of  the  drug.  Employ  the  above  mouth-wash  or  one 
composed  of  a  saturated  solution  of  chlorate  of  potassium. 
Order  gr.  y^-jj  of  atropin  twice  a  day,  and  in  bad  cases  spray 
the  mouth  with  peroxid  of  hydrogen  and  use  silver  nitrate 
locally  (gr.  xx  to  Sj)-  Give  stimulants  (iron,  quinin,  and  strych- 
nin) and  nutritious  food.  A  weekly  Turkish  bath  is  of  great 
service.  In  chronic  hydrargyrism  stop  the  administration  of 
the  drug,  use  tonics,  stimulants,  open-air  exercise,  Turkish 
baths,  and  nutritious  food.  The  chlorid  of  gold  and  sodium 
forms  a  substitute  for  mercury.  The  use  of  iodid  of  potas- 
sium is  of  questionable  value  in  ptyalism. 

Treatment  of  Complications  in  the  Secondary  Stage. — 
The  complications  of  the  secondar}^  stage  usually  require 
local  applications  in  addition  to  general  remedies.  Mucous 
patches  in  the  mouth  should  be  touched  with  bluestone 
every  day,  an  astringent  mouth-wash  being  employed  several 
times  daily.  If  the  patches  ulcerate,  they  should  be  touched 
n 


258  SYPHILIS. 

once  a  day  with  lunar  caustic ;  if  these  areas  proliferate, 
they  should  be  excised  and  cauterized.  Vegetations  or  grow- 
ing papules  on  the  skin  must,  if  calomel  powder  fails  to  re- 
move them,  be  cut  away  with  scissors  and  be  cauterized  with 
chromic  acid  or  with  the  Paquelin  cautery.  Condylomata 
demand  washing  with  ethereal  soap  several  times  daily, 
thorough  drying,  dusting  with  equal  parts  of  calomel  and 
subnitrate  of  bismuth  or  with  borated  talcum,  and  covering 
with  dry  bichlorid  gauze.  If  these  simple  procedures  fail, 
excise  and  cauterize. 

For  psoriasis  of  the  palms  and  soles  diachylon  ointment, 
mercurial  plaster  or  painting  with  tincture  of  iodin  should 
be  employed.  Ulcers  of  paronychia  are  dressed  with  iodo- 
form and  corrosive-sublimate  gauze.  Deep  cutaneous  ulcers 
are  cleaned  once  a  day  with  ethereal  soap,  sprayed  with  per- 
oxid  of  hydrogen,  dressed  with  iodoform  and  corrosive-subli- 
mate gauze  and  bandaged.  When  the  process  of  granula- 
tion is  well  established  dress  with  i  part  of  unguent,  hydrarg. 
nitratis  to  7  parts  of  cosmolin.  In  sarcocele  mercurial  oint- 
ment should  be  rubbed  into  the  skin  of  the  scrotum  or 
the  testicle  be  strapped.  In  alopecia  the  hair  should  be 
kept  short,  and  every  night  the  scalp  should  be  cleaned 
with  equal  parts  of  green  soap  and  alcohol  rubbed  into  a 
lather  with  water.  After  the  soap  has  been  washed  out  some 
hair  tonic  should  be  rubbed  into  the  scalp  with  a  sponge.  A 
favorite  preparation  of  Erasmus  Wilson's  consisted  of  the 
following  ingredients : 

R.   01.  amygd.  dil., 

Liq.  ammonise,  da  f^j ; 

Sp.  rosemarini, 

Aquse  mellis,  aa  f^iij. — M. 

Ft.  lotio. 

One  part  of  tincture  of  cantharides  to  8  parts  of  castor  oil 
may  be  rubbed  into  the  scalp.  Solutions  of  quinin  are  es- 
teemed by  some. 

In  treating  persistent  skin-lesions,  inunctions,  injections, 
fumigations  or  mercurial  baths  may  be  used.  Baths  are 
suited  to  patients  with  delicate  skins,  to  those  whose  diges- 
tion fails  when  mercury  is  given  by  the  mouth,  and  to  those 
whose  lungs  will  not  tolerate  fumigations.  Half  an  ounce 
of  corrosive  sublimate  with  4  scruples  of  sal  ammoniac 
are  mixed  in  about  4  ounces  of  water ;  this  is  added  to  a 
bath  at  a  temperature  of  95°  F.  The  patient  gets  into  this 
bath,  covers  the  tub  with  a  blanket,  leaving  only  his  head 


TERTIARY  STAGE.  259 

exposed,  and  remains  in  the  bath  an  hour  or  so.  Mercurial 
baths  may  rapidh'  cause  sahvation. 

In  every  case  of  syphihs,  no  matter  what  constitutional  or 
local  treatment  is  used,  the  general  health  of  the  patient  must 
be  watched  and  the  use  of  tobacco  stopped,  as  its  employment 
renders  certain  the  development  of  mucous  patches  and  causes 
them  to  persist.  The  use  of  alcohol  as  a  beverage  must  be 
interdicted  :  it  is  to  be  employed  only  as  a  medicine  for  debility 
and  weakness  of  assimilation.  An  open-air  life  to  a  great 
degree  must  be  insisted  upon,  and  care  observed  as  to  pro- 
tection from  damp  and  cold.  Flannels  must  be  worn  in  winter. 
Every  morning  the  patient  should  sponge  the  chest  and 
shoulders  with  cold  or  tepid  water  and  then  with  alcohol, 
and  dr}'  himself  with  a  rough  towel.  He  should  take  a  hot 
bath  twice  a  week,  or  a  Turkish  bath  once  a  week.  He 
should  wash  the  anus  and  nates  after  every  stool,  and  ought 
to  dust  the  axillae,  scrotum,  perineum,  and  internatal  region 
once  a  day  with  borated  talcum.  The  teeth  are  to  be  looked 
to  and  put  in  perfect  order,  a  soft  brush  being  used  twice  a 
day  and  an  astringent  mouth-wash  being  frequently  employed. 
The  diet  must  contain  liberal  amounts  of  meat  and  milk. 
The  patient  should  be  weighed  weekly :  any  falling  off  in 
weight  is  an  indication  for  the  administration  of  tonics,  con- 
centrated food,  and  cod-liver  oil.  If  a  patient's  health  con- 
tinues to  fail  during  a  mercurial  course,  the  drug  should  be 
stopped  for  some  time  and  the  patient  be  treated  with  iron, 
chlorid  of  gold  and  sodium,  hot  baths,  fresh  air,  cod-liver  oil, 
and  nourishing  foods.  In  treating  secondary  syphilis,  give 
mercur}-  for  at  least  eighteen  months  and  better  for  two  years. 
Reminders  require  mixed  treatment  (mercurials  and  iodids). 

Tertiary  Stage. — If  at  any  time  during  the  case  there 
appear  tertiary  symptoms,  the  patient  should  be  put  on  mixed 
treatment.  In  any  case,  after  two  years  of  mercury  add  iodid 
of  potassium  to  the  treatment.  White's  rule  is  to  use 
mixed  treatment  for  at  least  six  months  [\i  any  symptoms 
appear^  the  six-months  course  dating  from  their  disappear- 
ance. This  emphasizes  the  fact  that  the  iodids  alone  will  not 
cure  tertiar}^  syphilis.  In  obstinate  tertiary  lesions  and  in 
nervous  syphilis  the  iodids  should  be  run  up  to  an  enormous 
amount  (from  30  to  250  grains  per  day).  Sometimes  people 
can  take  large  doses  of  iodid  when  small  doses  produce  iodism. 
Cyon  explains  this  curious  fact  as  follows  :  small  doses  com- 
bine with  some  products  of  the  thyroid  gland  and  form  toxic 
iodo-thyrin.  Large  doses  are  diuretic,  form  soluble  salts, 
and  are  rapidly  eliminated.     An  easy  way  to  give  iodid  is  to 


26o  SYPHILIS. 

order  a  saturated  solution  each  drop  of  which  equals 
one  grain  of  the  drug.  Each  dose  of  the  iodid  is  given  one 
hour  after  meals  and  in  at  least  half  a  glass  of  water.  If 
the  iodid  disagrees,  it  may  be  given  in  water  containing  one 
dram  of  aromatic  spirit  of  ammonia  or  in  milk.  The  iodid 
of  sodium  may  be  tolerated  better  than  the  potassium  salt, 
or  the  iodids  of  sodium,  potassium,  and  ammonium  may  be 
combined.  In  giving  the  iodids  begin  with  a  small  dose. 
During  a  course  of  the  iodid  always  give  tonics  and  insist  on 
plenty  of  fresh  air.  Arsenic  given  daily  tends  to  prevent  skin- 
eruptions.  The  iodids  when  they  disagree  produce  iodism 
— a  condition  which  is  made  manifest  by  a  flow  of  mucus  from 
the  nose,  conjunctival  irritation,  a  bad  taste  in  the  mouth,  ex- 
haustion, anorexia,  nausea,  and  tremor.  In  some  subjects  there 
are  outbreaks  of  acne,  vesicular  eruptions,  or  even  bullae  or 
hemorrhages.  Iodism  calls  for  the  abandonment  of  the 
drug,  and  the  administration  of  increasing  doses  of  Fowler's 
solution,  of  arsenic,  of  laxatives,  of  diuretic  waters,  or  if 
there  is  great  exhaustion,  of  stimulants.  In  some  cases 
belladonna  is  of  service.  Some  patients  who  cannot  take 
the  alkaline  iodids  may  take  syrup  of  hydriodic  acid.  After 
the  patient  has  been  for  six  months  under  mixed  treatment 
without  a  symptom,  stop  all  treatment  and  await  develop- 
ments. If  during  one  year  no  symptoms  recur,  the  patient 
is  probably  cured ;  if  symptoms  do  recur,  there  must  be  six 
months  more  of  treatment  and  another  year  of  watching. 
Fournier  has  insisted  that  it  is  a  great  wrong  to  tell  a  syph- 
ilitic that  he  can  never  marry.  He  must  not  marry  until  he 
is  cured,  and  he  is  not  cured  until,  after  the  cessation  of  the 
use  of  iodid,  he  goes  one  year  without  treatment  and  with- 
out symptoms. 

Hereditary  Syphilis. — Transmitted  cong-enital  syph- 
ilis is  a  hereditary  syphilis  manifest  at  birth.  Acquired  syph- 
ilis (except  in  the  case  of  a  woman  who  obtains  the  disease 
from  a  fetus)  always  presents  the  chancre  as  an  initial  lesion ; 
hereditary  syphilis  never  does.  Hereditary  syphilis  may  pre- 
sent itself  at  birth,  and  usually  shows  itself  within,  at  most, 
the  first  six  months  of  extra-uterine  life.  In  rare  cases  (tardy 
hereditary  syphilis)  the  disease  does  not  become  manifest 
until  puberty. 

Rules  of  Inheritance. — According  to  von  Zeissl,^  the  rules 
of  inheritance  are  as  follows  : 

I.  If  one  parent  is  syphilitic  at  the  time  of  procreation,  the 
child  may  be  syphilitic. 

^  Pathology  and  Treatment  of  Syphilis. 


HEREDITARY  SYPHILIS.  26 1 

2.  Syphilitic  parents  may  bring  forth  healthy  children. 

3.  If  a  mother,  healthy  at  procreation,  bears  a  child  syph- 
ilitic from  the  father,  the  mother  must  have  latent  pox  or 
must  be  immune,  having  become  infected  through  the  pla- 
cental circulation.  She  often  shows  no  symptoms,  having 
received  the  poison  gradually  in  the  blood,  and  having  thus 
received,  it  may  be  said,  preventive  inoculations.  Certain  it 
is  that  mothers  are  almost  never  infected  by  suckling  their 
syphilitic  children  (Colles's  law). 

4.  If  both  parents  were  healthy  at  the  time  of  procreation, 
and  the  mother  afterward  contracts  syphilis,  the  child  may 
become  s}-philitic,  and  the  earlier  in  the  pregnancy  the  mother 
is  diseased,  the  more  certain  is  the  child  to  be  tainted.  This 
is  known  as  "infection  in  utero." 

5.  The  more  recent  the  parental  syphilis,  the  more  cer- 
tain is  infection  of  the  offspring.  The  children  are  often 
stillborn. 

6.  When  the  disease  is  latent  in  the  parents  it  is  apt  to  be 
tardy  in  the  children. 

7.  The  longer  the  time  which  has  passed  since  the  dis- 
appearance of  parental  symptoms,  the  more  improbable  is 
infection  of  the  children. 

8.  In  most  instances  parental  syphilis  grows  weaker,  and 
after  the  parents  beget  some  tainted  children  they  bring  forth 
healthy  ones. 

Syphilis  in  the  mother  is  more  dangerous  to  the  offspring 
than  syphilis  in  the  father.  The  frequent  immunity  of  the 
mother  is  due  to  the  fact  that  her  tissues  produce  antitoxins 
under  the  influence  of  the  slowly  absorbed  virus. 

Many  women  who  labor  under  hereditary  syphilis  are 
sterile.  Many  syphilitic  women  abort,  usually  before  the 
eighth  month,  most  commonly  in  the  fifth  month.  The  fetus 
very  often  dies  at  an  early  period  of  gestation.  This  may 
be  due  to  a  gummatous  placenta  or  to  a  degeneration  of 
placental  follicles. 

Evidences  of  Hereditary  Syphilis  (manifest  at,  or  oftener 
soon  after,  birth). — Hutchinson  says  that  at  birth  the  skin  is 
almost  invariably  clear.  In  from  six  to  eight  weeks  "  snuf- 
fles "  begin,  which  are  soon  followed  by  a  skin-eruption,  by 
body-wasting,  and  by  a  chain  of  secondary  symptoms  (iritis, 
mucous  patches,  pains,  condylomata,  etc.).  The  child  looks 
hke  a  withered-up  old  man.  Eruptions  are  met  with  on  the 
palms  and  soles.  Intertrigo  is  usual.  Cracks  occur  at  the 
angles  of  the  mouth,  and  leave  permanent  radiating  scars. 
The  abdomen  is  tumid,  and  there  is  apt  to   be   exhausting 


262  SYPHILIS. 

diarrhea.  The  secreting  and  absorbing  glands  of  the  in- 
testinal tract  atrophy/  Enlargement  of  spleen  and  liver 
occurs.  Sometimes  synovitis  or  arthritis  arises.  Atrophic 
lesions  may  appear  in  the  bones.  In  the  skull  the  bone  may 
be  softened  by  removal  of  its  salts  or  be  thinned  by  the 
pressure  of  the  brain.  In  the  long  bones  the  epiphyseal 
lines  suffer,  the  attachment  of  the  epiphyses  to  the  shafts  is 
weak,  and  separation  is  easily  induced.  Epiphysitis  is  com- 
mon, rarely  causes  pain,  and  rarely  leads  to  suppuration, 
except  in  children  who  are  old  enough  to  walk  (Coutts). 
Osteophytic  lesions  of  the  skull  are  shown  by  symmetrical 
spots  of  thickening  upon  the  parietal  and  frontal  bones  (nati- 
form  skulls).  In  the  long  bones  osteophytes  are  frequently 
formed.  A  child  with  precocious  hereditary  syphilis  is  apt 
to  die,  but  if  it  lives  from  six  months  to  one  year  the  symp- 
toms for  a  time  disappear  and  for  years  the  disease  may  be 
latent.  Diagnosis  is  difficult  after  the  third  or  fourth  year, 
especially  if  the  disease  be  associated  with  rickets  or  tuber- 
culosis. When  later  symptoms  arise  they  m.ay  be  various, 
namely :  noises  in  the  ears,  often  followed  by  deafness ; 
interstitial  keratitis ;  dactylitis  (specific  inflammation  of 
all  the  structures  of  a  finger) ;  synovitis  in  any  joint;  ossify- 
ing nodes ;  developmental  osseous  defects ;  suppurative 
periostitis  ;  ulcerations  ;  death  of  bone  ;  falling  in  of  the  nose  ; 
nervous  maladies ;  occasionally  sarcocele,  etc.  In  hereditary 
syphihs  the  eye-symptoms  are  of  great  diagnostic  impor- 
tance. In  212  cases  of  congenital  syphilis  Fournier  found 
eye-trouble  in  loi.  Keratitis  and  choroiditis  are  the  most 
usual  forms  (Silex).  Bone-trouble  occurs  in  almost  half  of 
the  cases,  but  is  not  often  severe  enough  to  cause  symptoms. 
The  tongue  often  shows  a  smooth  base  (Virchow's  sign). 
Hirschberg  believed  choroiditis  to  be  pathognomonic.  The 
descendants  of  syphilitic  parents  may  exhibit  certain  patho- 
logical conditions  which  are  not  directly  syphilitic.  Fournier 
calls  such  phenomena  parasyphilitic.  Among  these  phe- 
nomena are  arrest  of  development  of  the  body  at  large  or  of 
special  structures,  weakness  of  constitution,  and  stigmata  of 
degeneration. 

Diagnosis. — In  the  diagnosis  of  hereditary'  syphihs  the  con- 
dition of  the  teeth  is  of  considerable  importance :  the  temporary 
teeth  decay  soon,  but  present  no  characteristic  defect.  If  the 
upper  permanent  central  incisors  are  examined,  they  are 
often  but  by  no  means  always  found  defective.  Other  teeth 
may  show  defects,  but  in  these  alone  are  characteristic  defects 

1  Coutts,  in  Brit.  Med.  Jour.,  1S94,  No.  1643- 


HEREDITAR  Y  S\ THILIS.  263 

likely  to  appear.  In  hereditary  syphilis  they  may  present  an 
appearance  of  marked  deviation  from  health,  and  are  then 
called  "  Hutchinson  teeth  "  (Fig.  66).  If  they  are  dwarfed,  too 
short  and  too  narrow,  and  if  they  display  a  single  central 
cleft  in  their  free  edge,  then  the 

diagnosis   of  syphilis  is  prob-  .^^.-^.^r-^^^.^.y.,-.,^ 

able.     If  the   cleft   is    present  \ 

and  the  dwarfing  absent,  or  if       "^iOwJ^"^'  '^~^^J^0 
the  peculiar  form  of  dwarfing  '•'^  ^ 

be  present    without    any   con-  F:g.  66.-Hutchinson  teeth, 

spicuous    cleft,    the    diagnosis 

may  still  be  made.  The  view  that  teeth  of  this  nature  prove 
the  existence  of  hereditary  syphilis  and  that  they  occur  only  in 
syphilis  has  been  abandoned  by  Hutchinson  himself.  In  fact, 
'  only  one-fifth  of  congenital  s>-philitics  have  these  teeth  and 
one'-third  of  the  cases  of  Hutchinson  teeth  are  in  individuals 
free  from  syphilis.  In  early  infancy  the  diagnosis  of  syphilis 
is  made  by  the  snuffles,  the  broad  nose,  the  skin-eruptions, 
the  wasted  appearance,  the  sores  at  the  mouth-angles,  the 
tenderness  over  bones,  condylomata,  and  the  histor>'  of 
the  parents.  The  diagnosis  at  a  later  period  is  made  by  the 
existence  of  symmetrical  interstitial  keratitis,  choroiditis,  the 
smooth  base  of  the  tongue,  deafness  which  comes  on  without 
pain  or  running  from  the  ear,  ossifying  nodes,  white  radiat- 
ing scars  about  the  mouth-angles,  sunken  nose,  natiform 
sk'uU,  deformit}-  of  long  bones,  painless  inflammation  of 
epiphyses,  and'Hutchinson  teeth.  It  must  be  remembered 
that  a  child  born  apparently  healthy  and  presenting  no  sec- 
ondary symptoms  may  show  bone-disease,  keratitis,  or 
syphilitic  deafness  at  pubert}'. 

Treatment. — In  infants  mercurial  inunctions  are  to  be  used 
until  the  svmptoms  disappear,  but  mercuiy  must  not  be 
forced  or  be  continued  too  long  after  the  symptoms  are  gone. 
There  must  be  rubbed  into  the  sole  of  each  foot  or  the  palm 
of  each  hand  5  grains  of  mercurial  ointment  ever>^  morning 
and  night.  Brodie  advised  spreading  the  ointment  (in  the 
strength  of  3J  to  the  ounce)  upon  flannel  and  fastening  it 
around  the  child's  belly.  If  the  skin  is  so  tender  that  mer- 
cury must  be  administered  by  the  mouth,  order  that  gr.  -^  to 
gr.  \  of  mercury  with  chalk^  with  i  grain  of  sugar,  be  taken 
three  times  a  day  after  nursing.  If  tertiaiy  symptoms  appear, 
and  in  any  case  when  the  secondaries  disappear,  give  gr.  ss  to 
gr.  j  or  more  of  iodid  of  potassium  several  times  a  day  in 
syrup.  White  advocates  the  continuance  of  the  mixed  treat- 
ment intermittently  until  puberty.     Local  lesions  require  local 


264  TUMORS   OR  MORBID    GROWTHS. 

treatment,  as  in  the  adult.  A  syphilitic  child  must  be  nursed 
by  its  mother,  as  it  will  poison  a  healthy  nurse.  If  the  baby 
has  a  sore  mouth,  it  must  be  fed  from  a  bottle ;  and  if  the 
mother  cannot  nurse  the  child,  it  must  be  brought  up  on  the 
bottle.  For  the  cachexia  use  cod-liver  oil,  iodid  of  iron, 
arsenic,  and  the  phosphates. 

XVII.  TUMORS  OR  MORBID  GROWTHS. 

Division. — Morbid  growths  are  divided  into  (i)  neo- 
plasms and  (2)  cysts. 

Neoplasms. — A  neoplasm  is  a  pathological  new  growth 
which  tends  to  persist  independently  of  the  structures  in 
which  it  lies,  and  which  performs  no  physiological  function. 
A  hypertrophy  is  differentiated  from  a  tumor  by  the  facts 
that  it  is  a  result  of  increased  physiological  demands  or  of 
local  nutritive  changes,  and  that  it  tends  to  subside  after  the 
withdrawal  of  the  exciting  stimulus.  Further,  a  hypertrophy 
does  not  destroy  the  natural  contour  of  a  part,  while  a  tumor 
does.  Inflammation  has  marked  symptoms :  its  swelling 
does  not  tend  to  persist,  it  terminates  in  resolution,  organiza- 
tion or  suppuration,  and  examination  of  a  section  under  the 
microscope  differentiates  it  from  tumor.  Inflammation,  too, 
has  an  assignable  exciting  cause.  A  new  growth  is  a  mass 
of  newly  formed  tissue ;  hence  it  is  improper  to  designate  as 
tumors  those  swellings  due  to  extravasation  of  blood  (as  in 
hematocele),  or  of  urine  (as  in  ruptured  urethra),  to  displace- 
ment of  parts  (as  in  hernia,  floating  kidney,  or  dislocation  of 
the  liver),  or  to  fluid  distention  of  a  natural  cavity  (as  in 
hydrocele  or  bursitis). 

Classes  of  Tumors. — There  are  two  classes  of  tumors ; 
the  first  class  includes  those  derived  from  or  composed  of 
ordinary  connective  tissue  or  of  higher  structures.  These 
all  originate  from  cells  which  are  developed  from  the  meso- 
blast.  There  are  two  groups  of  connective-tissue  tumors : 
{a)  the  typical,  benign,  or  innocent,  which  find  their  type  in 
the  healthy  adult  human  body ;  and  {li)  the  atypical  or  malig- 
nant, which  find  no  counterpart  in  the  healthy  adult  human 
body,  but  rather  in  the  immature  connective  tissues  of  the 
embryo. 

The  second  class  of  tumors  include  those  which  are 
derived  from  or  composed  of  epithelium :  {a)  the  typical,  or 
innocent,  composed  of  adult  epithelium  ;  and  {U)  the  atypical, 
or  malignant,  composed  of  embryonic  epithelium. 

Miiller's  Law. — Miiller's  law  is  that  the  constituent  ele- 


CACSES.  265 

ments  of  neoplasms  ahva}'s  have  their  types,  counterparts, 
or  close  imitations  in  the  tissues,  either  embryonic  or  mature, 
of  the  human  body. 

Vircho"w's  Law. — \'irchow's  law  is  that  the  cells  of  a 
tumor  spring  from  pre-existing  cells.  There  is  no  special 
tumor-cell  or  cancer-cell. 

The  term  "  heterologous "  is  no  longer  used  to  signify 
that  the  cellular  elements  of  a  tumor  have  no  counterpart 
in  the  healthy  organism,  but  is  employed  to  signify  that  a 
tumor  deviates  from  the  type  of  the  structure  from  which  it 
takes  its  origin  (as  a  chondroma  arising  from  the  parotid 
gland).  Tumors  when  once  formed  almost  invariably  in- 
crease and  persist,  though  occasionally  warts,  exostoses, 
and  fatt}'  tumors  disappear  spontaneously.  Tumors  may 
ulcerate,  inflame,  slough,  be  infiltrated  with  blood,  or  undergo 
mucoid,  calcareous,  or  fatty  degeneration. 

Causes. — The  causes  of  tumors  are  not  positi\"eh-  recog- 
nized, those  alleged  being  but  theories  var\'ing  in  probability 
and  ingenuit}^ 

The  inclusion  theory  of  Colinlicini  supposes  that  more 
embr\'onic  cells  exist  than  are  needful  to  construct  the  fetal 
tissues,  that  masses  of  them  remain  in  the  tissues,  and  that 
these  ma}'  be  stimulated  later  into  active  growth.  The 
embryonic  hypothesis  seems  to  receive  a  certain  force  from 
the  facts  that  exostoses  do  sometimes  develop  from  portions 
of  unossified  epiphyseal  cartilage,  and  that  tumors  often  arise 
in  regions  where  there  was  a  suppression  of  a  fetal  part, 
closure  of  a  cleft,  or  an  involution  of  epithelium  (epithelioma 
is  usual  at  mucocutaneous  junctions).  This  theon".  which 
does  not  explain  the  origin  of  most  neoplasms,  cannot  suc- 
cessfully be  maintained  even  as  a  common  predisposing 
cause. 

Hereditation  is  extreme!}'  doubtful.  S.  W.  Gross  found 
hereditar}'  influence  b}'  no  means  frequent  in  cancer  of  the 
breast.  It  is  affirmed  b}'  some,  denied  by  others,  and  doubted 
by  a  number.  At  most,  hereditar}'  influence  ma}'  onl}'  pre- 
dispose. Nevertheless,  cases  have  occurred  which  cannot 
be  explained  b}'  the  term  coincidence.  In  the  celebrated 
"  ]\Iiddlesex  Hospital  case,"  a  woman  and  five  daughters 
had  cancer  of  the  left  breast.  A.  Pearce  Gould  had  charge 
of  a  woman  for  cancer  of  the  left  breast.  The  mother  of 
this  patient,  the  mother's  two  sisters,  and  two  of  the  mother's 
cousins  had  died  of  cancer.  Power  reports  a  remarkable 
instance  of  famify  predisposition  to  cancer.  A  patient  had 
his  right  breast  removed  for  cancer  in   1896.     In  1897  can- 


266  TUMORS   OR   MORBID    GROWTHS. 

cerous  glands  were  removed  from  the  axilla.  In  1898  he 
was  seen  again  with  an  irremovable  recurrent  growth.  His 
father  died  of  cancer  of  the  breast.  He  had  two  brothers, 
one  of  whom  died  of  cancer  of  the  throat  when  sixty-five 
years  of  age,  the  other  having  died  of  cancer  of  the  axilla 
when  he  was  only  twenty-four  years  old.  Of  his  eight  sisters, 
four  died  of  cancer  of  the  breast,  and  the  two  who  are  living 
both  suffer  from  cancer  of  the  breast.  One  sister  died  when 
an  infant,  and  one  died  after  giving  birth  to  a  child.^ 

Injury  and  inflammation  may  undoubtedly  prove  exciting 
causes.  A  blow  is  not  infrequently  followed  by  sarcoma; 
the  irritation  of  a  hot  pipe-stem  may  excite  cancer  of  the 
lip ;  the  scratching  of  a  jagged  tooth  may  cause  cancer  of 
the  tongue  ;  chimney-sweeps'  cancer  arises  from  the  irrita- 
tion of  dirt  in  the  scrotal  creases  ;  and  warts  often  arise  from 
constant  contact  with  acrid  materials. 

Physiological  activity  favors  the  development  of  sarcoma, 
and  physiological  decline  favors  the  development  of  carcinoma. 

Parasitic  Influence. — This  theory  does  not  maintain  that 
the  tumor  is  the  parasite,  but  that  it  contains  the  parasite, 
although  Pfeiffer  and  Adamciewicz  did  at  one  time  assert 
that  a  cancer-cell  is  not  a  body-cell,  but  a  parasite  resem- 
bling an  epithelial  cell.  Some  facts  render  a  parasitic  origin 
of  malignant  groAvths  not  improbable ;  as,  for  instance,  the 
likeness  of  some  tumors  to  infective  granulomata,  their  occa- 
sional secondary  development  in  distant  parts  of  the  body, 
the  resemblance  of  the  secondary  to  the  primary  growths, 
and  the  tenacity  of  their  persistence.  A  parasitic  origin  of 
cancer  is  pointed  to  by  its  geographical  distribution,  the  dis- 
ease being  very  common  in  low  and  marshy  districts  (Havi- 
land). 

Some  surgeons  believe  that  cancer  is  contagious,  but  most 
observers  deny  it.  Guelliott,  of  Rheims,  believes  that  cancer 
is  primarily  a  local  infection.  He  believes  this  because 
Morea  and  Hanau  have  inoculated  it  from  one  animal  to 
another  of  the  same  species,  and  if  this  can  be  brought 
about  experimentally  he  sees  no  reason  why  it  cannot  happen 
accidentally.  This  surgeon  says  that  cancer  is  very  un- 
equally distributed,  that  genuine  cancer-centers  and  "  cancer- 
houses  "  exist,  and  that  numerous  cases  of  accidental  infec- 
tion have  occurred.^  Mayet,  of  Lyons,  holds  that  cancer 
can  be  reproduced  by  grafting  or  by  the  injection  of  cancer- 
fluid.     Graf  could  not  find   "  cancer-houses  "   after  a  careful 

1  Brit.  Med.  Jour.,  July  i6,  1S98. 
^  Am.  Jour.  Med.  Sci.,  June,  1895. 


CAUSES.  267 

search.^  Geissler  claims  to  have  produced  the  disease  in  a 
doo-  by  planting  fragments  of  cancer  in  the  subcutaneous  tis- 
sue and  vaginal  tissue,  but  Czerny,  Rosenbach,  and  others 
dispute  the  claim.  Mauser  disputes  the  assertion  that  can- 
cer must  be  an  infectious  disease  because  it  is  followed  by 
secondary  growths.  Secondary  growths  in  an  infectious 
disease  are  caused  by  the  bacterium  ;  secondary  growths  in 
cancer  are  caused  by  the  transferrence  of  cells  of  the  primary 
growth.-  Hauser  says  with  truth  that  the  close  connection 
between  innocent  and  malignant  growths  renders  the  parasite 
view  untenable,  because  to  hold  it  we  would  be  forced  to 
believe  that  every  tumor  has  a  special  parasite  or  that  one 
parasite  may  cause  many  kinds  of  tumor. 

There  seems  to  be  no  doubt  that  autotransference  of  can- 
cer can  occur,  although  it  rarely  does  so.  Sippel  has  re- 
ported a  case  in  which  vaginal  carcinoma  developed  at  the 
point  where  the  vagina  was  in  contact  with  a  pre-existing 
cancer  of  the  portio.^  Cornil  has  seen  cancer  transferred 
from  one  of  the  labia  majora  to  the  other,  and  from  one  lip 
to  the  other.  Geissler  was  unable  to  transplant  cancer,  and 
Gratia  also  failed  in  his  attempts.  Duplay  and  Bazin  say 
that  transmissibility  is  possible,  but  only  under  conditions 
which  are  not  practically  realized.  Haviland  believes  strongly 
in  "  cancer-houses."  ■* 

Tillmanns  elaborately  discussed  the  subject  of  cancer  in 
the  Congress  of  1895.  His  conclusions  seem  most  sound 
and  scientific.  He  says  there  is  no  evidence  of  a  bacterial 
origin  of  cancer.  The  parasitic  origin  has  not  been  proved, 
and  protozoa  have  not  certainly  been  found.  Cancer  can  be 
transferred  from  one  part  to  another  part  of  the  same  indi- 
vidual, or  from  one  individual  to  another  of  the  same  species, 
but  never  to  one  of  a  different  species.  It  is  possible  that 
cancer  can  spread  by  contagion ;  this  is  very  rare,  but  can 
happen  (as  when  penile  cancer  is  followed  by  cervix  cancer 
in  a  wife).  Because  it  is  sometimes  possible  to  transfer^  can- 
cer, this  does  not  prove  that  the  disease  is  parasitic  or  infec- 
tious;  it  simply  shows  that  iissiie  has  been  successfully 
transplanted. 

Actinomycosis,  long  thought  to  be  a  true  tumor,  is  now 
known  to  arise  from  the  ray-fungus.  There  can  be  no  doubt 
that  changes  in  the  liver  which  practically  constitute  a  new 
growth  can  arise  from  the  growth  of  a  cell  called  by  Darier 

1  ArcJdv  f.  klin.  C/iii:,  1895,  1.,  p.  144- 

2  Hauser,  in  Biolog.  CentralbL,  Oct.  I,  1895. 

3  CentralbL  f.   Gyndk.,  No.  4,  1894.  *  Lancet,  April  27,  1894. 


268  TUMORS   OR  MORBID    GROWTHS. 

the  "  psorosperm."  A  disease  due  to  psorosperms  is  called 
a  "  psorospermosis."  It  is  affirmed  by  some  that  molluscum 
contagiosum,  follicular  keratosis,  cancer,  and  Paget's  disease 
are  due  to  psorosperms.  Some  claim  to  find  the  parasite  in 
all  cases  of  cancer,  while  others  can  find  it  in  only  4  or  5 
per  cent,  of  the  cases. 

Heneage  Gibbes  affirms  ^  that  dilatation  of  the  bile-ducts 
of  a  rabbit's  liver  is  caused  by  the  chronic  irritation  arising 
from  multiplication  of  the  coccidium  oviforme  in  them,  and 
not  in  the  columnar  cells  of  the  bile-ducts,  as  has  been 
stated;  and,  further,  that  the  large  majority  of  glandular 
cancers  show  nothing  that  can  be  considered  parasitic,  the 
suspicious  appearances  noted  in  some  few  cases  being  due 
to  endogenous  cell-formation.  The  coccidium  oviforme  is 
a  genus  of  the  sporozoa,  class  protozoa,  the  lowest  division 
of  the  animal  kingdom.  To  this  class  belong  the  monera 
and  infusoria. 

Malignant  and  Innocent  Tnmors. — JNIalignant 
growths  infiltrate  the  tissues  as  they  grow ;  benign  tumors 
only  push  the  tissues  away;  hence  malignant  tumors  are 
not  thoroughly  encapsuled,  while  innocent  tumors  are  encap- 
suled.  Malignant  tumors  grow  rapidly ;  innocent  tumors 
grow  slowly.  MaHgnant  tumors  become  adherent  to  the 
skin  and  cause  ulceration ;  innocent  tumors  rarely  adhere 
and  rarely  cause  ulceration.  jMany  malignant  tumors  give 
rise  to  secondary  growths  in  adjacent  lymphatic  glands  (can- 
cer, except  in  the  esophagus  and  antrum  of  Highmore,  always 
does  so) ;  sarcoma  rarely  causes  them,  unless  the  growth  be 
melanotic  or  unless  it  arises  from  the  testicle  or  tonsil. 
Innocent  tumors  never  cause  secondary  lymphatic  involve- 
ment, although  the  glands  near  the  tumor  may  enlarge  from 
accidental  inflammatory  complications.  The  malignant 
tumors,  especially  certain  sarcomata  and  soft  cancers,  may 
be  followed  by  Secondary  growths  in  distant  parts  and 
various  structures  (bones,  viscera,  brain,  muscles,  etc.); 
innocent  tumors  are  not  followed  by  these  secondar}^  repro- 
ductions, although  multiple  fatty  tumors  or  multiple  lympho- 
mata  may  exist.  Malignant  tumors  destroy  the  general 
health  ;  innocent  tumors  do  not  unless  by  the  accident  of 
position.  Malignant  tumors  tend  to  recur  after  removal ; 
innocent  tumors  do  not  if  operation  Avas  thorough.  The 
special  histological  feature  of  a  malignant  growth  is  the 
possession  by  its  cells  of  a  power  of  reproduction  which 
knows  no  limit,  the  cells  of  the   tumor  living   among  the 

1  The  American  Journal  of  Medical  Sciences,  July,  1893. 


LIPOMA  TA.  269 

body-cells  like  a  parasite,  and  invading  and  destroying  the 
body-cells. 

Classification. — Tumors  may  be  classified  as  follows  : 

I.  Connective-tissue  tumors. 

1.  Innocent  tumors,  or  those  composed  of  mature  con- 

nective tissue : 
Lipomata,  or  fatty  tumors ;  fibromata,  or  fibrous  tu- 
mors ;  chondroinata,  or  cartilaginous  tumors  ;  osteo- 
inata,  or  bony  tumors ;  odontomata,  or  tooth-tumors ; 
inyxomata,  or  mucous  tumors ;  myomata,  or  muscle- 
tumors  ;  neuromata,  or  tumors  upon  nerves  ; 
gliomata,  or  tumors  composed  of  neuroglia ; 
angiomata,  or  tumors  formed  of  blood-vessels ; 
lymphangiojuata,  or  tumors  formed  of  lymphatic 
vessels.  The  term  lymphoma,  meaning  a  tumor 
of  a  lymphatic  gland,  was  formerly  applied  to  any 
hypertrophy  of  a  lymphatic  gland,  no  matter 
whether  caused  by  syphilis,  tubercle,  or  Hodgkin's 
disease.  The  term  has  been  abandoned  except  as 
expressing  enlargement  of  a  gland,  and  does  not 
convey  any  suggestion  as  to  the  cause. 

2.  Malignant  tumors,  or  those  composed  of  embryonic 

connective  tissue : 
Sarcomata   (including    endotheliomata)  and  adrenal 
tumors. 

II.  Epithelial  tumors. 

1.  Innocent  tumors,  or  those  composed  of  mature  epi- 

thelial tissue : 
Adenomata,  or  tumors  whose  type  is  a  secreting  gland ; 
and  papillomata,  or  tumors  whose  type  is  found  in 
the  papillse  of  skin  and  mucous  membranes. 

2,  Malignant  tumors,  or  those  composed  of  embryonic 

epithelial  tissue : 
Carcinomata,  or  cancers. 

Innocent  Connective-tissue  Tumors. — These  growths 
mimic  or  imitate  some  connective  tissue  or  higher  tissue  of 
the  mature  and  healthy  organism. 

I/ipomata  are  congenital  or  acquired  tumors  composed 
of  fat  contained  in  the  cells  of  connective  tissue,  which  cells 
are  bound  together  by  fibers.  If  the  fibers  are  excessively 
abundant,  the  growth  is  spoken  of  as  a  "  fibrofatty  tumor." 
A  fatty  tumor  has  a  distinct  capsule,  tightly  adherent  to  sur- 
rounding parts,  but  loosely  attached  to  the  tumor ;  hence 
enucleation  is  easy.  Fibrous  trabeculae  run  from  the  capsule 
of  a  subcutaneous  lipoma  to  the  skin ;  hence  movement  of 


2/0  TUMORS   OR  MORBID    GROWTHS. 

the  integument  over  the  tumor  or  of  the  tumor  itself  causes 
dimphng  of  the  skin.  An  ordinary  circumscribed  hpoma  is 
of  doughy  softness,  is  lobulated,  of  uniform  consistence,  and 
on  being  tapped  imparts  to  the  finger  a  tremor  known  as 
pseudofluctuation.  A  fatty  tumor  is  mobile,  although  it 
may  be  attached  to  the  skin  at  points  by  trabeculse.  Lipo- 
mata  are  most  frequent  in  middle  life,  and  their  commonest 
situations  are  in  the  subcutaneous  tissues,  especially  of  the 
back  -or  of  the  dorsal  surfaces  of  the  limbs ;  they  usually 
occur  singly,  but  may  be  multiple  and  sometimes  symmetri- 
cal. Senn  described  the  case  of  a  woman  who  had  a  fatty 
tumor  in  each  axilla.  A  lipoma  may  grow  to  an  enormous 
size  (in  Rhodius's  case  the  tumor  weighed  sixty  pounds),  and 
the  growth  may  be  progressive  or  may  be  at  times  stationary' 
and  at  other  times  active.  The  skin  over  a  fatty  tumor 
sometimes  atrophies  or  even  ulcerates  ;  the  tumor  itself  may 
inflame  or  partly  calcify.  When  a  lipoma  has  once  inflamed 
it  becomes  immovable.  Subcutaneous  lipoma  of  the  palm 
of  the  hand  or  sole  of  the  foot  bears  some  resemblance  clin- 
ically to  a  compound  ganglion ;  it  is  apt  to  be  congenital. 
Lipomata  of  the  head  and  face  are  rare.  -  In  the  subcutaneous 
tissues  of  the  groins,  neck,  pubes,  axillae,  or  scrotum  a  mass 
of  fat  may  form,  unlimited  by  a  capsule  and  known  as  a  "  dif- 
fuse lipoma."  A  diffuse  lipoma  may  dip  down  among  the 
muscles.  Such  masses  attain  large  size.  The  typical  diffuse 
lipoma  is  occasionally  seen  on  the  neck.  It  begins  back  of 
the  mastoid  process  on  one  side  or  on  both  sides.  When 
large,  it  completely  surrounds  the  neck,  a  huge  double  chin 
forming  in  front,  a  great  mass  hanging  on  each  side,  and  the 
posterior  portion  being  divided  into  two  halves  by  a  median 
depression.  A  nevolipoma  is  a  nevus  with  much  fibrofatty 
tissue.  A  very  vascular  fatty  tumor  is  called  lipoma 
telangiectodes.  If  the  tumor  stroma  contains  large  veins, 
the  growth  is  called  a  cavernous  lipoma.  A  tumor  contain- 
ing much  blood  can  be  diminished  in  size  by  pressure. 
Fatty  tumors  may  arise  in  the  subserous  tissue,  and  when  such 
a  growth  arises  in  either  the  femoral  or  inguinal  canal  or  the 
linea  alba  it  resembles  an  omental  hernia  and  is  spoken  of  as  a 
"  fat-hernia."  In  the  retroperitoneal  tissues  enormous  fibro- 
fatty tumors  occasionally  grow,  and  these  neoplasms  tend  to 
become  sarcomatous.  Lipomata  may  arise  from  beneath 
synovial  membranes  and  will  project  into  the  joints,  being 
still  covered  by  synovial  membrane.  Fatty  tumors  occasion- 
ally arise  in  submucous  tissues,  between  or  in  muscles,  from 
periosteum,  and  from  the  meninges  of  the  spinal  cord  (J. 


FIBROMATA.  2/1 

Bland  Sutton).  A  fatty  tumor  may  undergo  metamorpho- 
sis. The  stroma  may  be  attacked  by  a  myxomatous  process 
or  a  calcareous  degeneration.  The  fat-cells  themselves  may 
become  calcareous.  Oil-cysts  sometimes  form.  A  xanthoma 
is  a  growth  composed  of  fatty  tissue  in  and  about  which 
there  is  marked  infiltration  with  small  cells.  Such  a  tumor 
is  flattened  and  slightly  elevated.  Several  or  many  of  these 
growths  occur  in  the  same  person.  The  eyelids  are  tliQ 
most  common  seat  of  xanthoma.  The  tumor  may  undergo 
involution  or  may  become  sarcomatous. 

Diabetics  are  liable  to  develop  xanthomata. 

Treatment. — A  single  subcutaneous  lipoma  should  be  ex- 
tirpated. The  capsule  must  be  incised,  when  the  tumor  can 
be  torn  out  forcibly  or  can  be  enucleated  by  dissection ; 
drainage  is  always  employed  for  twenty-four  hours,  as  bu- 
tyric fermentation  will  be  apt  to  occur,  and  necrosis  of 
small  particles  of  fat  predisposes  to  infection.  Multiple  sub- 
cutaneous lipomata,  if  very  numerous,  should  not  be  inter- 
fered with  unless  troublesome  because  of  their  size  or  situa- 
tion, when  the  growth  or  growths  causing  trouble  should  be 
removed.  It  is  difficult  to  extirpate  entire  a  dififuse  lipoma, 
and  several  operations  may  be  needed  to  effect  complete  re- 
moval. Liquor  potassje  has  been  recommended  to  limit  the 
growth  of  multiple  lipomata  or  diffuse  lipoma ;  it  may  be 
taken  internally  for  a  considerable  time,  but  it  seems  to  be 
useless.  Subperitoneal  lipomata  are  rarely  diagnosticated 
until  the  belly  has  been  opened  or  the  growth  has  been  re- 
moved. 

F'ibromata  are  tumors  composed  of  bundles  of  fibrous 
tissue.  There  are  two  forms,  the  hard  and  the  soft.  A 
hard  fibroma  consists  of  wavy  fibrous  bundles  lying  in  close 
contact.  Here  and  there  connective-tissue  corpuscles  exist 
between  the  fibres.  A  fibroma  has  no  distinct  capsule, 
though  surrounding  tissues  are  so  compressed  as  to  simu- 
late a  capsule.  Fibromata  are  occasionally  congenital,  are 
most  usual  in  young  adults,  but  they  may  occur  at  any 
period  of  life,  and  in  any  part  of  the  body  containing  con- 
nective tissue.  Pure  fibromata,  which  are  rare,  are  generally 
solitary,  grow  slowly,  are  of  uniform  consistence,  have  not 
much  circulation,  and  are  hard  and  movable.  Fibromata  may 
form  upon  nerves,  they  may  arise  in  the  mammary  gland, 
they  may  develop  in  the  lobe  of  the  ear,  and  they  may 
spring  from  various  fibrous  membranes,  from  the  periosteum 
of  the  base  of  the  skull  (nasopharyngeal  fibromata),  and 
from  the  gums  (fibrous  epulides).     A  soft  fibroma   contains 


2/2  TUMORS    OR   MORBID    GROWTHS. 

much  areolar  tissue,  the  spaces  of  which  are  filled  with  fluid, 
so  that  the  tissue  seems  edematous.  Soft  fibromata  grow  from 
the  skin,  mucous  membranes,  subcutaneous  tissue,  intermus- 
cular planes,  and  periosteum.  Soft  fibromata  are  especially 
apt  to  arise  from  the  skin  of  the  scrotum,  labia,  inner  surface 
of  arm  and  thigh,  and  of  the  belly  wall  of  a  pregnant  woman. 
They  are  not  unusually  multiple,  grow  slowly  but  more  rap- 
idly than  the  hard  fibromata,  and  may  become  quite  large  and 
possess  distinct  pedicles.  Fibromata  may  become  cystic, 
calcareous,  osseous,  colloidal,. or  sarcomatous,  and  may  in- 
flame, ulcerate,  or  even  become  gangrenous. 

K  painful  subcutaneous  tubercle,  which  is  a  form  of  fibroma 
commonest  in  females,  arises  in  the  subcutaneous  cellular 
tissue,  usually  of  the  extremities.  It  is  firm,  very  tender, 
movable,  rarely  larger  than  a  pea,  and  the  skin  over  it  seems 
healthy.  Violent  pain  occurs  in  paroxysms  and  radiates  over 
a  considerable  area,  of  which  the  tubercle  is  the  center.  These 
paroxysms  may  occur  only  once  in  many  days  or  many  times 
in  one  day.  Pain  is  always  developed  by  pressure,  and  may 
be  linked  with  spasm.  Nerve-fibrillge  are  now  known  to 
exist  in  these  tubercles,  a  fact  which  was  long  denied. 

A^mol£Js  a  congenital  fibroma  of  the  skin  (Senn).  It  is 
roiihded  or  flat,  is  usually  pigmented,  is  apt  to  have  hairs 
growing  from  it,  and  varies  in  size  from  a  pin's  head  to  several 
inches  in  diameter.  The  tumor  rarely  grows  after  the  thir- 
teenth or  fourteenth  year.  A  mole  may  become  malignant, 
melanotic  carcinoma  may  arise  from  its  epithelial  structures, 
or  melanotic  sarcoma  from  its  connective-tissue  elements. 

Fibrous  epulis  is  a  fibroma  arising  from  the  gums  or  peri- 
odontal membrane  (J.  Bland  Sutton)  in  connection  with  a 
carious  tooth  or  retained  snag ;  it  is  covered  by  mucous 
membrane,  grows  slowly,  may  attain  a  large  size,  and 
sometimes  has  a  stem,  but  is  more  often  sessile.  It  may 
undergo  myxomatous  change  or  may  become  sarcomatous. 

Fibrous  tumors  may  arise  from  the  ovary,  the  intestine, 
and  the  larynx.  Pure  fibromata  of  the  uterus  are  very  rare, 
but  fibromyomata  are  very  common  (see  Myomata,  p.  278) ; 
hence  the  term  "  uterine  fibroid  "  should  be  abandoned. 

Molluscum  fibrosuin  is  an  overgrowth  of  the  fibrous  tissue 
of  both  skin  and  subcutaneous  structure.  Senn  excludes 
this  form  of  growth  from  consideration  with  fibromata  be- 
cause of  its  infective  origin.  It  may  be  limited  or  widely  ex- 
tended ;  it  may  appear  as  an  infinite  number  of  nodules  scat- 
tered over  the  entire  body  or  as  hanging  folds  of  fibrous 
tissue  in  certain  areas.     Keloid  is  a  fibroma  of  the  true  skin. 


FIBROMATA.  273 

It  is  a  hard,  fibrous,  vascular  growth,  with  a  broad  base,  aris- 
ing in  scar-tissue ;  it  is  crossed  by  pink,  white,  or  discolored 
ridges,  and  is  named  from  a  fancied  likeness  to  the  crab.  It 
occasionally  but  rarely  attacks  mucous  membrane.  It  is 
more  common  in  negroes  than  in  whites,  and  is  most  fre- 
quent in  the  cicatrices  of  burns,  though  it  may  arise  in  the 
scar  of  any  injury,  as  the  scar  from  piercing  the  ears,  and 
in  the  scars  of  syphilitic  lesions,  tubercular  processes,  small- 
pox, or  vaccination.  It  is  rare  in  early  childhood  and  in  old 
age.  It  grows  slowly,  lasts  for  many  years,  and  may  event- 
ually undergo  involution  and  disappear.  It  is  useless  to  re- 
move keloid  by  operation,  as  it  will  promptly  return.  The 
fibrous  tissue  of  keloid  springs  from  the  outer  walls  of  the 
blood-vessels  (Warren).  The  papillae  of  the  skin  above  the 
tumor  are  destroyed  or  replaced  by  fibrous  tissue. 

Morphea,  spontaneous  or  true  keloid,  is  a  name  used  to 
designate  a  growth  of  this  description  which  does  not  arise 
from  a  scar  ;  but  it  seems  certain  that  scar-tissue  was  present, 
though  possibly  in  small  amount  from  trivial  injury. 

Fibrous  and  papillomatous  growths  covered  with  endo- 
thelium may  spring  from  any  serous  membrane.  Such  a 
growth  of  the  choroid  plexus  calcifies  early  and  constitutes 
a  psammoma.  All  psammomata  are  not  fibrous,  some  are 
gliomatous  and  some  are  sarcomatous.  A  cholesteatoma 
is  a  fibrous  growth  covered  with  endothelium  and  containing 
layers  of  crystalline  fat.  It  occurs  especially  in  the  pia 
mater,  and  is  called  a  pearl  tumor. 

Treatment. — When  in  accessible  regions  fibromata  should 
be  emadeated.  Fibromata  should  not  be  left  alone,  because 
any  fibrous  tumor  may  become  a  sarcoma.  If  a  hard  fibro- 
ma of  the  skin  exists  the  skin  is  incised  and  the  tumor  is 
"  shelled  out."  A  soft  fibroma  is  removed  by  an  incision 
carried  round  the  base  of  its  pedicle.  A  painful  subcuta- 
neous tubercle  should  be  excised.  If  a  mole  shows  the 
slightest  disposition  to  enlarge,  or  if  it  is  subjected  to  press- 
ure or  irritation,  it  should  be  removed,  because  if  allowed 
to  remain  it  might  develop  into  a  malignant  growth. 
It  is  often  desirable  to  remove  a  hairy  or  pigmented 
mole,  not  only  because  it  may  become  malignant, 
but  also  because  it  is  unsightly.  Epulis  requires  the 
cutting  away  of  the  entire  mass,  the  removal  of  the  related 
snag  or  carious  tooth,  and  sometimes  the  biting  away  of  a 
portion  of  the  alveolus  with  rongeur  forceps.  A  naso- 
pharyngeal fibrous  polyp  usually  contains  sarcomatous 
elements   or    becomes  a  spindle-cell  sarcoma.     If  it  has  a 

18 


274  TUMORS   OR   MORBID    GROWTHS. 

pedicle,  it  may  be  removed  by  the  cautery  loop.  In  a  severe 
case  a  part  of  the  superior  maxillary  bone  is  removed  by 
osteoplastic  resection  to  permit  of  extirpation.  Keloid  should 
not  be  operated  upon  :  it  will  only  return,  and  will  also  recur 
in  the  stitch-holes.  Trust  to  time  for  involution,  or  use  press- 
ure with  flexible  collodion,  by  which  method  J.  M.  DaCosta 
cured  a  case  following  small-pox.  The  administration  of  thy- 
i-oid  extract  may  be  of  benefit  (a  gr.  v  tablet  three  or  four 
times  a  day).  This  drug  must  be  given  cautiously,  as  it  may 
cause  attacks  characterized  by  fever,  dyspnea,  and  rapid 
pulse.  Thiosinnamin  hypodermatically  has  been  used,  it  is 
claimed,  with  benefit.  A  lo  per  cent,  solution  is  made,  and 
from  lO  to  15  minims  can  be  injected  into  the  gluteal  mus- 
cles every  third  day. 

Chondromata  (enchondromata)  are  tumors  formed  either 
of  hyaline  cartilage,  of  fibrocartilage,  or  of  both.  Chondro- 
mata are  apt  to  arise  from  certain  glands,  the  long  bones, 
the  pelvis,  the  rib-cartilages,  and  the  bones  of  the  hands  or 
feet,  and  often  spring  from  unossified  portions  of  epiphy- 
seal cartilage.  They  may  be  single  or  multiple,  and  are 
most  commonly  met  with  in  the  young.  They  have  dis- 
tinct adherent  capsules  ;  they  grow  slowly,  and  if  of  osseous 
origin  progressively  hollow  out  the  bones  by  pressure ; 
they  cause  no  pain ;  they  impart  a  sensation  of  firmness 
to  the  touch,  unless  mucoid  degeneration  forms  zones  of 
softness  or  fluctuation  ;  they  are  inelastic,  smooth  or  nod- 
ular, immovable,  and  often  ossify.  A  chondroma  may  grow 
to  an  enormous  size.  A  chondroma  of  the  parotid  gland 
or  testicle  practically  always  contains  sarcomatous  elements, 
and  any  chondroma  may  become  a  sarcoma.  Chondromata 
are  notably  frequent  in  persons  who  had  rickets  in  early  life. 
Ecchondroses,  which  are  "  small  local  overgrowths  of  carti- 
lage "  (J.  Bland  Sutton),  arise  from  articular  cartilages,  espe- 
cially of  the  knee-joint,  and  from  the  cartilages  of  the  larynx 
and  nose.  Loose  or  floating  cartilages  in  the  joints  may  be 
broken-off  ecchondroses  or  portions  of  hyaHne  cartilage 
which  are  entirely  loose  or  are  held  b}^  a  narrow  stalk,  and 
which  arise  by  chondrification  of  villous  processes  of  the 
synovial  membrane  ;  only  one  or  vast  numbers  may  exist; 
one  joint  may  be  involved,  or  several ;  they  may  produce 
no  symptoms,  but  usually  produce  from  time  to  time  violent 
pain  and  immobility  by  acting  as  a  joint-Avedge.  An  ecchon- 
droma  may  arise  within  the  medullary  canal  of  a  long  bone, 
from  foci  of  dormant  cartilage,  and  may  lead  to  the  develop- 
ment of  a  solitary  cyst  of  large    size    by    softening  of  the 


OSTEOMATA.  2/5 

tumor.  The  femur  is  the  most  usual  site  of  disease.  It 
begins  very  insidiously  and  progresses  gradually.  There  are 
slight  lameness,  trivial  pain,  tenderness  below  the  level  of  the 
trochanter,  apparent  shortening  and  some  bulging  of  bone. 
The  bone  may  bend  or  at  some  spot  may  thin  so  that  the 
cyst  can  be  felt.  Such  a  bone  fractures  from  slight  force, 
and  after  a  fracture,  v^^hen  the  effused  blood  and  inflammatory 
exudate  have  been  absorbed,  a  tumor  can  be  distinctly  de- 
tected. A  solitary  cyst  of  a  long  bone  is  apt  to  be  regarded 
clinically  as  a  sarcoma  (Bergmann-Virchow). 

Treatment, — Remove  chondromata  whenever  possible, 
for,  if  allowed  to  remain  undisturbed,  they  are  apt  to  resent 
this  hospitality  by  becoming  sarcomatous.  Incise  the  cap- 
sule and  take  away  the  growth,  using  chisels  and  gouges 
if  necessary.  Incomplete  removal  means  inevitable  recur- 
rence. Amputation  is  very  rarely  demanded.  Loose  bodies 
in  the  joints,  if  productive  of  much  annoyance,  are  to  be 
removed,  the  joint  being  opened  with  the  strictest  antiseptic 
care.  Amputation  is  sometimes  performed  for  a  solitary  cyst 
of  a  long  bone,  the  surgeon  having  looked  upon  the  growth 
as  sarcomatous.  If  a  correct  diagnosis  is  arrived  at,  an  at- 
tempt should  be  made  to  remove  the  cyst  without  amputation. 
Bergmann  succeeded  in  extirpating  such  a  mass  from  the  femur. 

Osteomata. — Osteomata  are  tumors  which  are  composed 
of  osseous  tissue.  J.  Bland  Sutton  says  that  osteomata  are 
ossifying  chondromata.  Osteomata  take  origin  from  bone, 
cartilage,  connective  tissue,  especially  tissue  near  the  bone, 
serous  membrane,  and  certain  glands  and  organs.  Com- 
pact osteomata,  which  are  identical  in  structure  with  the 
compact  tissue  of  bone,  arise  from  the  frontal  sinus,  mastoid 
process,  external  auditory  meatus,  and  other  regions  in 
those  beyond  middle  life ;  they  are  small,  smooth,  round, 
densely  hard,  with  small  and  occasionally  cartilaginous  bases. 

Cancellous  osteomata,  which  comprise  the  great  majority 
of  bone-tumors,  are  similar  in  structure  to  cancellous  bone. 
They  spring  from,  and  are  crusted  with,  cartilage ;  they  may 
have  fibrous  capsules,  and  are  often  movable  when  recent, 
but  soon  become  fixed ;  they  have  broad  bases,  are  angled, 
nodular,  firm  (but  not  so  hard  as  are  the  compact  osteo- 
mata), painless  except  when  pressed,  occur  particularly  at 
the  ends  of  long  bones,  may  grow  to  large  size,  and  are 
commonest  in  youth.  Osteomata  near  joints  become  over- 
laid by  bursse,  which  in  rare  instances  communicate  with 
an  adjacent  joint. 

The  term  exostosis  has  been  used  as  being  synonymous  with 


2/6  TUMORS   OR   MORBID    GROWTHS. 

osteoma,  but  wrongly  so,  as  an  exostosis.is  an  irregular, 
local,  bony  growth  which  does  not  tend  to  progress  without 
limit,  and  which  is,  hence,  not  a  tumor.  A  true  exostosis 
is  seen  in  the  ossification  of  a  tendon-insertion,  in  a  limited 
growth  from  one  of  themaxjllary  bones,  and  in  a  local  growth 
from  the  last  phafanx  of  the  big  toe,  which  latter  form  of 
growth  is  known  as  a  "  subungual  exostosis."  Exostoses  of 
the  retrocalcaneal  bursa  occasionally  arise  when  this  bursa  is 
inflamed.  Inflammation  of  this  bursa  is  known  as  Achillo- 
dynia  or  Albert's  disease.  The  bony  masses  sometimes 
found  in  the  brain,  lungs,  testicle,  various  glands,  and  tumors 
are  not  true  osteomata.  Osteomata  do  not  tend  to  become 
malignant  and  do  not  recur  after  removal. 

Treatment. — Osteomata  which  are  non-productive  of  pain 
or  trouble  do  not  demand  removal.  If  they  produce  pain 
by  pressure,  if  they  press  upon  important  structures,  if  they 
cause  annoying  deformities,  or  if  they  grow  rapidly,  then 
remove  them  by  means  of  chisels,  gouges,  or  the  surgical 
engine.  Subungual  exostosis  should  always  be  removed. 
The  nail  should  be  split  and  part  of  it  taken  away,  and  the 
bony  mass  be  gouged  away  or  be  cut  off  with  forceps. 

Odontotnata  ^  are  tumors  composed  of  tooth-tissue.  They 
spring  from  the  germs  of  teeth  or  from  developing  teeth. 
J.  Bland  Sutton  divides  them  into  (i)  those  springing  from 
the  follicle;  (2)  those  springing  from  the  papilla;  and  (3) 
those  springing  from  the  whole  germ. 

Epithelial  odontomes,  or  multilocular  cystic  tumors, 
arise  from  the  follicle,  occur  oftenest  in  the  lower  jaw,  dilate 
the  bone,  have  capsules,  and  are  made  up  of  masses  of  cysts 
which  are  filled  with  brown  fluid.  These  cysts  are  met 
with  most  frequently  before  the  age  of  twenty.  Follicular 
odontomes,  or  dentigerous  cysts,  oftenest  spring  from  the 
follicles  of  the  permanent  m'olars.  In  a  dentigerous  cyst 
there  exists  an  expanded  follicle  which  distends  the  bone, 
the  follicle  being  filled  with  thick  fluid  and  containing  a 
portion  of  a  tooth.  K  fibrous  odontomc  is  due  to  thickening 
of  the  tooth-sac,  which  prevents  eruption  of  the  tooth  ; 
fibrous  odontomes  are  usually  multiple,  and  are  apt  to  occur 
in  rickety  children.  A  ceine7itoine  is  due  to  enlargement, 
thickening,  and  ossification  of  the  capsule,  the  developing 
tooth  being  encased  in  cement.  A  compoiDid follicular  odon- 
tome  is  due  to  ossification  of  portions  only  of  an  enlarged 
and   thickened    capsule,    and    the    tumor    contains    bits  of 

*  This  section  is  abridged  from  J.  Bland  Sutton's  striking  chapter  upon  odon- 
tomes in  his  recent  work  on  Tumors. 


MYXOMA  TA.  '^17 


cementum,  portions   of  dentine    or  small  mis  hapen  teeth^ 
A  radicular   odontomc   springs  from  the  papilla  and  arises 
2^ter  the  crown  of  the  tooth  is  formed  and  while  the  roots  are 
?ormii-  hence  it  contains  dentine  and  cement,  but  no  en- 
amel. ^Composite  odontomes...  ^--^^ of  irregulai   shapeless 
masses    of   dentine,  cement,    and   enamel.     Al   the   above 
Srms    occur    in    man.     They  present   themselves    as   hard 
tumors  associated  with  teeth  or  m  an  area  where  teeth  have 
not  erupted.     Occasionally  an  odontome  simulates  necrosis  , 
it  is  surrounded  by  pus,  and  a  sinus  forms. 
^'  Treatmer.t.--The    diagnosis  is    scarcely  ever  made  unti 
after  incision ;  hence,  be  in  no  haste  to  excise  large  portions 
of  bo  e  for  a  doubtful   growth;  incise  first  and  see  if  it  be 
an  odontome,  which  requires  only  the  removal  of  an  imi^h- 
cated  tooth,  curetting  with  a  sharp  spoon,  and  packmg  with 

"  TOtlata  •  are   tumors    composed   of    mucous   tissue. 
The>  are  rare  as  independent   growths   although   myxoma- 
tous change  is  frequent  in  the  stroma  of  other  tumors     The 
tissue  typ?  of  thes^e  tumors   is   found  in  the  vitreous  humor 
of  the  eye  and  in  the  perivascular  tissues  of  the  umbilical 
cord  (Warton's  jelly).     Bowlby  states  that  myxomata  are 
in  reality  soft  fibromata  whose  intercellular  substance  has 
been  repkced  by  mucin.     The  myxomatous  state  may  be  a 
sta  "e  tn  the  formation  of  a  fibroma    a  stroma  not  having 
developed      Myxomata   may  result  from  myx^omatous  de- 
tnera?ron    of   cartilage,  of    muscle,  or    of  fibrous    tissue. 
These  tumors  are   soft,  dastic,  usually  pedunculated  tremu- 
lous and  vibratory.     The  stroma  is  very  delicate  and  carries 
'Zute  blood-vessels.  Cutting  into  a  myxon^a  cause- straw 
colored  clear  jelly  to  exude;  they  grow  slowly,  aie  encap 
sued  have  b^t  little  circulation,  and  the  diagnosis  may  be 
mpts^Te  before  removal  of  the  gi^wth.     Some  pathologists 
nlace   myxomata  among  the   malignant  tumois,  but  most 
?J^Sde7them  as  benigif  tumors,  though  they  tend  strong  y 
to  become  sarcomatous  (myxosarcomata).     A  sarcoma  may 

"1,7.LTraran3?irTe"sH„;  from  the  :nucous 
membranTof  the  nose,  the  frontal  sinus,  the  antrum,  the 
::mb  the  auditory  mektus,  and  the  ty-P-™  ^'from  th 
nolvDS^  ■  from  the  parotid  and  mammary  glands  ,  trom  tne 
LSieous  tissu'i,  the  nerve  sheaths,  the  mtennuscula 
septa,  the  rectum,  and  the  bladder  (P^'^P''),  ,j'''?:""J^3„lt 
congenital  but  occur  most  often  m  young  adults  as  a  result 
o?  inflammation.     A  sudden  increase  of  growth   md.cates 


2/8  TUMORS   OR  MORBID    GROWTHS. 

beginning  malignancy  (sarcomatous  change).  When  a  tumor 
begins  to  undergo  myxomatous  transformation  we  give  to  it 
a  compound  name ;  for  instance,  a  chondroma  undergoing 
myxomatous  change  is  a  chondromyxoma,  a  fibroma  under- 
going a  Hke  change  is  a  fibromyxoma,  etc. 

Mucous  polypi  grow  from  the  mucous  membrane  of  the 
nose,  particularly  from  the  outer  wall  near  the  middle  tur- 
binated bone,  and  often  from  the  roof  of  the  nose.  Mucous 
polypi  are  soft  and  jelly-like,  of  a  grayish  color,  and  have 
stems  or  pedicles ;  they  may  be  seen  through  the  anterior 
nares,  may  project  behind  the  veil  of  the  palate,  and  may 
bulge  out  from  the  passages  of  the  nose ;  they  may  be,  and 
usually  are,  multiple ;  they  may  be  present  in  one  nasal 
fossa  or  in  both  ;  and  they  occur  most  commonly  in  youths 
and  adults  between  the  ages  of  fifteen  and  thirty-five  years. 

Hydatid  moles  of  pregnancy  are  due  to  myxomatous 
changes  in  the  chorion. 

Treatment. — In  treating  myxomata,  remove  them  prompt- 
ly and  thoroughly,  because  of  the  danger  of  sarcomatous 
change.  Polyps  of  the  bladder  are  removed  by  means  of 
cutting-forceps  after  suprapubic  cystotomy  has  been  per- 
formed. Nasal  polyps  may  usually  be  twisted  off  or  be  re- 
moved by  the  wire  snare  or  galvanocautery.  Occasionally 
when  the  growths  are  numerous  and  recur  rapidly  after 
removal,  the  inferior  turbinated  bones  should  be  removed 
with  a  saw  (Rouge's  operation).  This  operation  secures 
ready  access  to  the  area  of  disease,  which  can  be  attacked 
radically.  A  very  soft  myxoma  breaks  up  when  removal 
is  attempted,  and  the  base  must  be  cauterized. 

Myomata  are  tumors  composed  of  unstriped  muscle-fiber 
mixed  often  with  fibrous  tissue  (leiomyomata).  Tumors  com- 
posed of  striated  muscle-fiber  and  spindle-cells  (rhabdomyo- 
mata)  are  very  rare  and  are  always  sarcomatous.  Leiomyo- 
mata are  found  in  the  womb,  in  the  prostate  gland,  in  the 
walls  of  the  gullet,  vagina,  stomach,  bladder,  and  bowel,  in 
the  broad  ligament,  ovary,  and  round  ligament,  in  the 
scrotum,  and  in  the  skin.  Myomata  usually  begin  during 
or  after  middle  age ;  they  are  encapsuled,  they  grow  slowly, 
they  are  firm  and  hard,  and  produce  annoyance  by  their 
size  and  weight  or  by  obstructing  a  viscus  or  channel.  A 
leiomyoma  of  the  posterior  portion  of  the  middle  of  the 
prostate  gland  is  known  as  "  a  middle  lobe." 

The  so-called  "  uterine  fibroid "  is  a  myoma  or  fibro- 
myoma.  Uterine  myomata  may  originate  within  the  walls 
of  the    womb    (intramural    myomata),    from    the    muscular 


AIYOMATA.  279 

structure  of  the  mucous  lining  (submucous  myomata),  or 
from  the  muscular  tissue  of  the  serous  covering  (subserous 
myomata).  Intramural  uterine  myomata  may  be  single  or 
multiple  and  may  grow  to  an  enormous  size.  Submucous 
myomata  project  into  the  cavity  of  the  womb  (fleshy  polyps), 
and  may  project  into  the  vagina.  They  distend  the  uterus 
and  are  often  accompanied  by  menorrhagia  or  metrorrhagia. 
In  some  rare  cases  the  projecting  tumor  is  detached  by 
Nature  and  the  patient  is  cured ;  in  some  cases  the  myoma 
becomes  gangrenous.  A  fleshy  polyp  may  produce  inver- 
sion of  the  fundus  of  the  womb.  Subserous  uterine  myo- 
mata cause  trouble  only  by  the  inconvenience  of  weight  or 
the  discomfort  of  pressure.  Uterine  myomata  are  com- 
monest in  single  women,  and  arise  most  frequently  between 
the  ages  of  twenty-five  and  forty-five.  Negro  women  are 
especially  prone  to  develop  such  tumors.  They  may 
never  produce  any  symptoms.  Some  of  these  growths,  by 
enlarging  until  they  ascend  above  the  pelvic  brim,  produce 
abdominal  distention ;  some  become  jammed  or  impacted 
in  the  pelvis,  and  produce  by  pressure  retention  of  urine, 
obstruction  to  the  passage  of  feces,  or  hydronephrosis. 
Impaction  may  occur  temporarily  at  each  menstrual  period. 
Many  myomata  produce  uterine  hemorrhage;  some  cause 
retroversion  of  the  womb ;  some  protrude  from  the  cervical 
canal ;  some  are  so  large  that  they  cause  disastrous  pressure 
upon  the  colon  (obstruction),  upon  the  iliac  veins  (intense 
edema),  or  upon  the  ureters  (hydronephrosis).  Uterine 
myomata  usually  shrink  after  the  menopause.  Pregnancy 
in  a  myomatous  womb  usually  ends  in  abortion.  Uterine 
myomata  may  undergo  fatty,  calcareous,  or  myxomatous 
change,  and  may  be  infected  by  septic  organisms  as  a  result 
of  the  use  of  a  uterine  sound  or  of  infection  of  the  pedicle 
after  oophorectomy.  Infection  of  a  uterine  myoma  causes 
great  enlargement,  elevated  temperature,  sweats,  and  ex- 
haustion. 

The  symptoms  of  myomata  of  the  alimentary  canal  are 
similar  to  or  identical  with  the  symptoms  of  malignant 
growths.  Myomata  of  the  skin  are  rare  growths  ;  they  are 
encapsuled,  firm  or  elastic,  and  painless. 

Treatment. — Cutaneous  myomata  are  removed  in  the  same 
manner  as  fibrous  tumors.  Uterine  myomata  are  treated  by 
rest  and  the  administration  of  ergot,  barium  chlorid,  and  dilute 
sulphuric  acid.  If  this  treatment  fails  to  arrest  serious 
bleeding  due  to  a  fleshy  polyp,  dilate  the  cervical  canal  and 
remove  the   erowth.     If  there  be  dangerous  bleedine  in  a 


280  TUMORS    OR   MORBID    GROWTHS;. 

woman  who  has  some  years  to  wait  for  the  menopause  and 
who  has  not  a  removable  polyp  as  the  cause,  perform 
oophorectomy  in  order  to  bring  on  an  artificial  menopause. 
When  a  myoma  becomes  impacted  at  each  menstrual  period 
remove  the  ovaries  and  Fallopian  tubes.  Subserous  myomata 
may  be  removed  from  the  uterus  after  abdominal  section, 
the  resuldng  wound  in  the  uterus  being  sutured.  Hyster- 
ectomy is  indicated  for  some  very  large  tumors,  for  tu- 
mors that  grow  after  the  menopause,  and  for  infected  myo- 
mata. If  the  abdomen  be  opened  to  perform  oophorectomy, 
and  the  tubes  and  ovaries  are  found  so  implicated  in  the 
growth  that  they  cannot  be  removed  completely,  or  the 
broad  ligament  is  found  so  drawn  out  that  a  safe  pedicle 
cannot  be  secured,  perform  a  hysterectomy.^  A  recent  sug- 
gestion for  the  shrinkage  of  uterine  myomata  is  to  ligate 
both  the  uterine  and  ovarian  arteries.  If  a  myoma  of  the 
prostate  cause  severe  obstrucdon,  perform  a  suprapubic  cys- 
totomy and  remove  the  major  pordon  of  the  enlarged  gland; 
or  make  both  a  suprapubic  and  a  perineal  opening,  push  the 
gland  into  the  perineum  and  shell  it  out  with  the  finger,  or 
make  permanent  suprapubic  drainage. 

Neuromata. — A  true  neuroma  springs  from  nerve-tissue 
(brain,  cord,  or  nerve-trunks);  it  is  composed  of  medullated 
or  non-medullated  nerve-fibers  which  form  a  plexus  or  net- 
work, and  which  are  not  continuous  with  the  fibers  of  the 
nerve-trunk  or  other  area  from  which  the  tumor  grows. 
True  neuromata,  which  are  rare  growths,  arise  during  mid- 
dle life;  they  are  small  in  size,  are  due  to  injury  or  hered- 
itary tendency,  and  they  may  be  single  or  multiple.  There 
is  usually  around  the  tumor,  rather  than  in  it,  severe  neu- 
ralgic pain,  which  is  greatly  intensified  by  dampness,  by 
blows,  or  by  rough  handling.  The  parts  below  a  neuroma 
are  cold,  swollen,  often  anesthetic,  and  frequently  present 
motor  paralysis  or  trophic  disorder.  A  false  neuroma  or 
neurofibroma  is  a  fibrous  tumor  growing  from  a  nerve-sheath, 
and  is  identical  in  structure  with  the  sheath.  False  neuromata 
may  be  single,  but  they  are  often  multiple ;  they  may  be  as 
small  as  peas  or  as  large  as  oranges ;  they  are  smooth  and 
movable,  and  may  cause  great  pain  or  may  be  painful  only 
when  pressed  or  struck  ;  they  may  spring  from  roots,  trunks, 
or  branches,  and  they  may  be  linked  with  the  disease  known 
as  "  molluscum  fibrosum."  In  plexiform  neuroma  some 
branches  of  a  nerve  enlarge  and  lengthen  like  an  artery  in  a 

'See  J.  Bland  Sutton's  admirable  article  on  "Uterine  Myomata"  in  his  work 
on  Tumors. 


GLIOMATA.  281 

cirsoid  aneurysm  ;  the  mass  feels  like  beads  or  like  a  bag 
of  worms ;  it  is  mobile,  and  no  pain  is  felt  on  moving  it ;  and 
it  is  generally  congenital.  In  plexiform  neuroma  the  nerve- 
sheath  undergoes  myxomatous  change.  Malignant  neuroma 
is  a  primary  sarcoma  of  a  ner\"e-sheath,  though  any  neuroma 
may  become  sarcomatous. 

Traumatic  neuromata  are  false  neuromata  and  are  occa- 
sionally well  exhibited  after  nerve-section  or  amputation. 
On  ner\e-section  the  distal  end  shrinks  and  atrophies,  the 
proximal  end  enlarges  and  becomes  bulbous.  A  trau- 
matic neuroma  is  composed  of  fibrous  tissue  which  con- 
tains nerve-fibers.  Such  a  growth  is  usualh',  but  not  always, 
painful  on  pressure  or  during  dampness,  and  is  most  com- 
monly seen  in  a  stump  which  did  not  heal  by  first  intention. 
In  performing  an  amputation  cut  the  nerves  high  up,  and 
thus  keep  them  out  of  the  scar,  permit  them  to  remain 
mobile  in  their  sheaths,  and  so  pre\'ent  a  tender  stump.  .V 
tender  stump  may  be  due  to  anchoring  of  a  nerve  in  a  scar, 
the  nerve  ceasing  to  glide  when  the  individual  moves  the 
extremity.  The  condition  known  as  painful  subcutaneous 
tubercle  was  discussed  on  p.  272. 

Treatment. — A  false  neuroma  is  to  be  removed,  if  possi- 
ble, without  destroying  the  nerve-trunk.  If,  in  removing  a 
neuroma,  it  is  necessary  to  exsect  a  portion  of  a  nen-e-trunk, 
alwa\'s  endeavor  to  suture  the  ends  of  the  divided  nerve  so 
as  to  facilitate  restoration  of  function.  For  multiple  neuro- 
mata— at  least  should  the  number  be  large  or  should 
molluscum  fibrosum  exist — surgery  can  do  nothing.  Plexi- 
form neuromata  may  often  be  remo\-ed,  but  amputation 
may  be  required.  Painful  neuromata  in  stumps  should  be 
excised. 

Gliomata. — These  tumors  are  composed  of  neuroglia, 
are  usualh^  single,  and  arise  in  the  brain,  rarely  in  the  cord, 
and  very  rarely  in  a  cranial  nerve. 

A  glioma  is  a  circumscribed  growth  in  contrast  to  a 
gliosis,  which  is  a  widespread  and  unlimited  h}-perplasia  of 
the  neuroglia.  Syringomyelia  is  due  to  gliosis  of  the  spinal 
cord. 

"  A  glioma  consists  of  cells  containing  rounded  or  o\"al 
nuclei  with  x&ry  little  protoplasm  and  fine  protoplasmic 
extensions  which  interlace  and  form  an  intercellular 
reticulum"  (Stengel). 

A  glioma  passes  insensibly  into  surrounding  tissue,  and 
there  is  no  distinct  edge  ;  it  is  harder  than  the  surroundincr 
tissue  ;  is  vascular  and  of  a  pink  or  red  color ;  and  the  nor- 


282  TUMORS   OR   MORBID    GROWTHS. 

mal  shape  of  the  part  is  often  very  Httle  altered,  although  the 
tumor  may  reach  the  size  of  a  lemon. 

Hemorrhage  may  take  place  into  a  glioma,  softening  may 
occur,  cavities  may  form,  or  the  growth  may  become  sar- 
comatous or  psammomatous.  The  symptoms  of  a  glioma 
of  the  brain  depend  on  the  situation. 

Treatment. — When  the  growth  can  be  localized  it  is 
justifiable  in  some  cases  to  attempt  its  removal.  Even  a 
partial  removal  may  be  of  benefit. 

Angiomata  or  Hemangiomata. — An  angioma  is  a 
tumor  composed  largely  of  dilated  blood-vessels.  The 
older  surgeons  called  such  growths  erectile  tumors.  Some 
of  the  so-called  angiomata  are  not  genuine  new  growths, 
but  are  due  to  dilatation  and  elongation  of  blood-vessels. 

Simple  or  capillary  angiomata,  nevi,  or  "  mother's 
marks,"  which  affect  the  skin  or  subcutaneous  tissue,  are 
composed  of  enlarged  and  twisted  capillaries  and  of  anas- 
tomosing vessels  surrounded  by  fat.  These  growths  are 
congenital  or  appear  in  the  first  few  weeks  of  life ;  they  are 
flat  and  slightly  raised,  and  are  of  a  bright-pink  color  if 
composed  chiefly  of  arterioles,  and  are  bluish  if  composed 
mainly  of  venules  ;  they  are  but  little  elevated ;  they  can 
be  almost  completely  emptied  by  pressure ;  they  occasion- 
ally pass  away  spontaneously,  but  usually  grow  constantly 
and  may  become  cavernous  ;  they  may  ulcerate  and  occasion 
violent  or  fatal  hemorrhage.  One  or  several  large  vessels 
connect  a  nevus  to  adjacent  blood-vessels.  Port-wine  or 
claret  stains  are  pink  or  blue  discolorations  due  to  superficial 
nevi  of  the  skin  ;  they  may  be  small  in  extent  or  they  may 
involve  a  very  large  area,  are  not  elevated,  and  do  not 
usually  spread.  Telangiectasis  is  a  form  of  nevus  involv- 
ing the  skin  and  subcutaneous  tissue  in  which  many  arte- 
rioles and  venules  exist.  Simple  angiomata  are  common 
on  the  forehead,  the  scalp,  the  face,  the  neck,  the  back,  and 
the  extremities.  They  may  appear  on  the  labia,  the  tongue, 
or  the  lips. 

Cavernous  angiomata,  or  venous  nevi,  resemble  in 
structure  the  corpora  cavernosa  of  the  penis;  there  are  large 
endothelial  lined  spaces  with  thin  walls  carrying  blood,  and 
there  may  be  distinct  vessels  as  well.  Arteries  send  blood 
into  the  spaces,  and  veins  receive  it  from  the  spaces.  These 
channels  and  sinuses  are  enormously  distended  capillaries. 
Cavernous  angiomata  arise  in  the  skin  and  subcutaneous  tis- 
sues ;  they  are  usually  congenital,  but  may  develop  from 
simple  angiomata  ;  they  are  purple  or   blue  in    color ;   are 


TREATMEXT  OF  ANGIOMATA    OR  HEMAXGIOMATA.    283 


more  distinctly  elevated  than  the  capillary  nevi ;  may  be 
either  cutaneous  or  subcutaneous  ;  swell  when  the  child  cries, 
and  are  apt  to  pulsate ;  they  may  be  emptied  b>'  pressure, 
and  often  look  like  cysts  with  very  thin  walls.  Cavernous 
angiomats  ma>-  arise  in  the  breast,  the  tongue,  the  lip,  the 
cheek,  the  gums,  the  subcutaneous  tissues,  or  the  muscles. 
If  an  angioma  contains  an  excess  of  fat,  the  growth  is  called 
a  "  nevoid  lipoma." 

Plexiform  ang-iomata  are  known  as  "  cirsoid  aneurysms  " 
or  aneurysms  by  anastomosis  (p.  324). 

Angiomata  noticed  soon  after  birth  may  disappear  com- 
pletely or  may  enlarge  progressively. 

Treatment. — These  growths  if  large  or  growing  must  be 
treated.  A  capillar}-  nevus  can  often  be  quickly  cured  by 
touching  it  with  fuming  nitric 
acid.  A  second  application 
of  acid  may  be  required. 
The  growth  may  be  de- 
stroyed by  heat — "a  knit- 
ting-needle at  a  dull-red 
heat  or  the  galvanocautery  " 
(WhartonV  The  application 
of  eth}-late  of  sodium  or  the 
employment  of  electrolysis 
will  destro}-  the  growth.  As- 
tringent injections  are  dan- 
gerous unless  the  base  of 
the  nevus  is  ligated,  because 
they  may  lead  to  the  forma- 
tion of  emboli. 

Small  port-wine  stains 
may  be  removed  by  electrol- 
ysis   or    multiple    incisions, 

but  extensive  stains  are  ineffaceable.  Small  nevi 
Hgated  under  harelip-pins;  larger  nevi  may  be 
lated  in  sections  by  the  Erichsen  suture  (Fig 
may  be  completelv  excised.  Excision  is  usually 
plan  for  the  cure  of  angiomata.  It  is  rapid,  thorough,  and 
leaves  but  a  trivial  scar.  Excision  should  always  be 
emploved  if  we  feel  sure  that  the  edges  of  the  wound  can  be 
subsequently  approximated  and  that  there  will  not  be  a 
dangerous  loss  of  blood.  It  is  sometmies  justifiable  to 
exci'se  an  angioma  even  when  approximation  of  the  wound 
will  obviously  be  impossible.  In  such  a  case  the  raw  sur- 
face should  be  covered  with  Thiersch  grafts. 


Fig.  67.— Method  of  applying  Erichsen' 
ligature. 


may  be 

strangu- 

67),    or 

the  best 


284  TUMORS   OR   MORBID    GROWTHS. 

Most  superficial  nevi  and  many  cavernous  angiomata  can 
be  treated  by  excision.  The  incisions  must  be  beyond  the 
dilated  vessels.  In  large  angiomata  involving  the  skin  a-nd 
also  deeper  parts,  or  involving  a  structure,  like  the  lip,  which 
it  is  undesirable  to  remove,  electrolysis  should  be  employed. 
The  operation  should  be  carried  out  with  aseptic  care,  and, 
if  the  tumor  is  large,  an  anesthetic  should  be  given. 

The  positive  pole  produces  a  firm  and  hard  clot.  One 
or  more  needles  connected  with  the  positive  pole  are  inserted 
in  the  tumor,  and  these  needles  are  insulated  to  within  about 
a  quarter  of  an  inch  of  their  points.  A  flat  moist  pad  is 
placed  upon  the  skin  near  the  tumor  and  attached  to  the 
negative  pole,  and  the  pad  is  moved  from  time  to  time 
during  the  operation. 

From  twenty-five  to  seventy-five  milliamperes  is  the 
proper  strength,  and  the  current  is  passed  for  ten  minutes. 
The  current  is  increased  for  a  moment  before  withdrawing 
the  needles,  otherwise  they  will  stick  to  the  tissue  and  cause 
bleeding  when  torn  loose.  After  the  withdrawal  of  the 
needles  the  nevus  will  be  found  to  be  hard,  but  the  hard- 
ness will  gradually  disappear.  It  may  be  necessary  to 
repeat  the  operation  a  number  of  times  at  intervals  of  ten 
days.^ 

I/ymphangiomata  are  tumors  composed  of  dilated 
lymph-vessels,  and  are  often,  though  not  invariably,  con- 
genital. A  lymphatic  nevus  is  a  colorless  or  faintly  pink 
elevation ;  if  it  is  punctured  with  a  needle,  lymph  flows  from 
the  puncture.  One  or  several  nevi  may  be  present  in  the 
same  individual.  The  dilatation  is  due  to  blocking  of  the 
lymph-channels.  Local  lymphangioma  of  the  tongue  is 
manifested  by  a  cluster  of  papillary  projections  containing 
lymph.  Macroglossia  is  a  congenital  enlargement  of  the 
anterior  portion  of  the  tongue,  which  enlargement  grows 
more  and  more  marked  until  finally  the  tongue  is  forced  far 
out  of  the  mouth.  This  condition  of  tongue  enlargement  is 
due  to  lymphangioma  of  the  mucous  membrane.  Lymph 
scrotum  is  due  to  a  similar  growth.  A  collection  of  these 
warty-looking  dilatations  is  called  lymphangiectasis.  Just 
as  cavernous  angiomata  constitute  a  variety  of  blood-vessel 
tumors,  so  cavernous  lymphangiomata  constitute  a  variety 
of  lymph-vessel  tumors,  and  the  spaces  of  the  latter  are 
filled  with  lymph  instead  of  with  blood.  Areas  affected 
with  lymphangiectasis  are  liable  to  repeated  attacks  of  ery- 
sipelas-like   inflammation.      Whether   this    inflammation    is 

^  Cheyne  and  Burghard's  Manual  of  Surgical  Treatment. 


MALIGXANT  COXXECTIVE-TISSUE    TUMORS.  285 

causative  or  secondary  is  not  known.  In  tropical  countries 
blockino-  of  Ivmpli-channels  may  be  brought  about  by  the  hla- 
ria  sanguinis' hominis,  a  parasite  which  lurks  m  the  ymph-ves- 
sels  durincT  the  dav  and  is  found  in  the  blood  only  at  night. 
Lvmphan|iectasis 'is  often  the  first  stage  of  an  elephantiasis 

'Treatment.— A  Ivmphatic  nevus  requires  excision  in 
macroo-lossia  the  bulk  of  the  mass  should  be  removed  by  a 
V-shaped  cut,  the  mucous  membrane  bemg  sutured  so  as  to 
cover  the  stump.  In  conditions  due  to  the  filaria,  anilin-blue 
has  been  given  internallv  with  advantage. 

Malignant  Connective -tissue  Tumors,   or   Sarco- 
mata.—The  sarcomata  are  composed  of  embryonic  tissue- 
cells  the  intercellular  substance  being  very  scanty.     They 
develop  from  connective  tissue,  have  no  definite  stroma,  and 
contain  no  lymphatics,  and  the  constituent  cells,  as  a  rule, 
proliferate  with  great  rapidity.     The  rapidly  growing  forrns 
are  verv  vascular,  the  blood  flowing  in  vessels  whose  walls 
are  ver^'  thin  or  running  in  canals  hned  by  endothelium  and 
bounded  by  sarcomatous  cells.     Such  a  tumor  may  pulsate 
and  have  a  bruit,  and  hemorrhage  often  takes  place  into  its 
substance.      A  slow-growing  sarcoma  has  but  few  vessels. 
Sarcoma   tends   strongly  to   infiltrate   adjacent  parts.     Ihe 
arowth  disseminates  bv  means  of  the  blood  and  the  vessel- 
walls  particles  of  the  tumor  being  carried  by  the  venous  blood 
to  the  heart  and  from  this  organ  to  the  lungs,  where  they 
lodcxe  and  form  secondar>^   growths.      Emboli    from   these 
secondary  foci  are  sent  out  by  the  arterial  blood  to  various 
portions  of  the  body,  as  the  bones,  kidneys,  bram,  liver,  etc. 
This  process  is  known  as  "  metastasis."     In  some  cases  sar- 
coma is  disseminated  wddely  throughout  the  body    almost 
all  the  tissues  showing  minute  white  spots  of  secondare-  sar- 
coma which  resemble  tubercles.     Such  widespread  dissemi- 
nation  is   called   sarcomatosis.     Sarcoma  follows  the  veirt- 
walls  for  considerable  distances  and  builds  elongated  masses 
of   tumor-substance    inside   the   veins.      The   tumor    may 
possess    a  capsule  when  it  is   in  an   early  stage,  but  soon 
loses  this  except  in  very  slow-growing  vaneties  or  m  mixed 
forms  crrowing  bv  central  proliferation,  but  secondar>^  sar- 
comata''are    ofte'n    encapsuled.     Sarcomata    may    arise    at 
any  age   from    birth    to    extreme    senility,   but    ttiey   are 
commonest  during  youth  and  early  middle  age      They  are 
not  hereditar^-,  and  often  follow  traumatism  and  mflamma- 
tion      Thev  may  be  primary  or  may  arise  frorn  mahgriant 
chancre   in 'an  innocent  connective-tissue  growth  (chondro- 
sarcoma, fibrosarcoma,  etc.).     A  sarcoma  does  not  tend  to 


286  TUMORS   OR  MORBID    GROWTHS. 

affect  lymphatic  glands  except  by  the  accident  of  its  position  ; 
and  if  it  does  impHcate  them,  the  sarcomatous  elements  are 
carried  rather  by  the  vein-walls  and  blood  than  by  the  lymph 
(melanotic  sarcoma  implicates  adjacent  glands,  and  so  does 
sarcoma  of  the  tonsil  or  of  the  testicle).  The  skin  over  the 
tumor  may  give  way,  a  bleeding  fungus-mass  protruding 
(fungus  haematodes),  and  suppuration  may  cause  septic  en- 
largement of  adjacent  glands.  After  removal  of  a  sarcoma 
the  growth  tends  to  recur,  and  the  recurrent  tumor  may  be 
either  more  or  less  maHgnant  than  its  predecessor,  the  degree 
of  malignancy  being  in  direct  ratio  to  the  number  and  small- 
ness  of  the  cells.  A  sarcoma  is  malignant  by  local  tissue- 
infection  and  by  dissemination.  Sarcomata  rarely  cause  pain 
when  they  are  not  ulcerated.  They  are  commonest  in 
the  skin  and  connective  tissue  of  the  extremities,  but  they 
arise  also  from  bone,  neuroglia,  periosteum,  the  lymphatic 
glands,  the  breast,  the  testicle,  the  eyeball,  the  parotid,  and 
other  parts.  Not  unusually  a  pigmented  mole  becomes 
sarcomatous.  Hemorrhages  into  a  sarcoma  often  occur, 
with  the  result  of  suddenly  increasing  its  size  and  forming 
blood-cysts.  Sarcomata  are  subject  to  partial  fatty  degenera- 
tion, to  myxomatous  changes  which  produce  cavities  filled 
with  fluid,  to  calcification,  and  occasionally  to  necrosis  of 
large  masses. 

Varieties  of  Sarcomata. — The  following  species  of  sarco- 
mata are  recognized : 

1.  Round-celled  Sarcoma. — A  tumor  composed  of  round 
or  spherical  cells.  The  intercellular  substance  is  scanty, 
the  mass  is  soft  and  vascular,  and  grows  with  great  rapid- 
ity. It  often  softens,  and  may  become  cystic.  The  cells 
may  be  small  or  large.  The  smaller  the  cell  the  more 
malignant  the  growth.  A  growth  composed  of  small,  round 
cells  is  the  most  malignant  form  of  sarcoma.  Lympho- 
sarcoma is  a  form  of  round-celled  sarcoma  which  arises  from 
lymphatic  glands,  lymphoid  tissues,  the  thymus  gland,  and 
some  other  structures.  The  structure  of  a  lymphosarcoma 
resembles  the  structure  of  a  lymph-gland.  Qhloroma  is  a 
form  of  lymphosarcoma,  arising  particularly  from  the  peri- 
osteum of  the  bones  of  the  cranium  and  face.  The  cells  con- 
tain greenish  pigment,  hence  the  name.  What  is  known  as 
glioma  of  the  eyeball  is  really  a  sarcoma  composed  of  small 
round  cells. 

2.  Spindle-celled  Sarcoma. — A  tumor  composed  of  large 
or  small  spindle-shaped  cells  lying  in  a  matrix,  which  may 
be  homogeneous,  but  which  may  show  some  attempt  at 


MALIGNANT  CONNECTIVE-TISSUE    TUMORS.  287 

fiber-formation.  Angular  cells  and  stellate  cells  are  often 
present.  The  cells  may  be  placed  in  columns,  which  are  at 
some  places  nearly  parallel,  and  which  at  others  diverge  or 
interlace.  Often  there  is  no  orderly  arrangement.  Spindle- 
celled  sarcomata  are  usually  harder  than  round-celled 
growths,  but  are  sometimes  quite  soft.  Cystic  changes  may 
occur.  If  there  is  a  large  amount  of  intercellular  substance 
the  growth  is  known  as  a  fibro-sarcoma.  A  rhabdomyoma 
is  really  a  spindle-celled  sarcoma  containing  striated  muscle- 
cells.  The  spindle-celled  sarcomata  often  contain  cartilage. 
Spindle-celled  growths  are  by  no  means  as  malignant  as 
round-celled  tumors.  Often  they  do  not  show  any  tendency 
to  metastasis.  The  greater  the  amount  of  intercellular  sub- 
stance, and  the  fewer  and  smaller  the  cells,  the  less  the  ma- 
lignancy. Spindle-celled  growths  constitute  the  majority  of 
sarcomata  met  with  in  practice. 

3.  Giant-celled  or  myeloid  sarcoma  is  characterized  by  the 
presence  of  very  large  cells,  with  many  nuclei  looking  exactly 
like  the  myeloplaques  of  bone-marrow.  The  remainder  of 
the  growth  is  composed  of  spindle-cells,  of  round-cells,  or 
of  both  spindle-cells  and  round-cells.  Such  a  growth  is 
maroon-colored  on  section.  It  arises  most  usually  from 
bone,  especially  from  the  interior  of  a  long  bone,  hence  is 
often  called  osteosarcoma.  It  may,  however,  arise  from 
other  structures  than  bone.  It  is  the  least  malignant  form 
of  sarcoma.  Metastases  rarely  occur,  and  the  growth  often 
admits  of  complete  extirpation  and  cure. 

4.  Alveolar  Sarcoma. — A  tumor  containing  both  round- 
cells  and  spindle-cells,  and  characterized  by  the  formation  of 
acini,  filled  with  round-cells  of  large  size  resembling  epithe- 
lioid cells.  The  walls  of  the  acini  are  formed  of  spindle-cells 
and  fibrous  tissue,  and  in  these  trabeculae  are  the  blood- 
vessels. The  collection  of  the  cells  into  the  alveoli  makes 
the  structure  resemble  that  of  a  cancer.  Such  growths  are 
often  pigmented.  Alveolar  sarcomata  arise  particularly  from 
moles  of  the  skin,  but  may  arise  from  lymphatic  glands, 
serous  membranes,  the  testicle,  and  other  parts.  Such 
growths  are  very  malignant. 

5.  Melanotic  or  Black  Sarcoma. — The  color  of  such  a  tumor 
is  due  to  pigment  in  the  cells  or  matrix.  These  growths 
are  usually  composed  of  round-cells,  but  may  consist  of 
spindle-cells,  and  they  are  sometimes  alveolar.  Melanotic 
sarcomata  spring  from  parts  which  contain  pigment  (the 
skin  and  the  choroid  coat  of  the  eye) ;  they  are  apt  to  arise 
from    pigmented    moles ;    they    are    very    malignant ;    they 


288  TUMORS   OR   MORBID    GROWTHS. 

implicate  related  lymphatic  glands,  and  during  their  existence 
the  urine  contains  pigment. 

6.  Hemorrhagic  sarcoma  is  a  sarcoma  containing  blood- 
cysts  which  result  from  parenchymatous  hemorrhages. 

7.  Angiosarcoina  takes  origin  from  the  outer  coat  of 
a  blood-vessel.  The  growth  is  often  very  vascular,  and  when 
the  blood-vessels  are  notably  dilated  the  tumor  is  called  a  tel- 
angiectatic sarcoma.  The  ordinary  forms  of  angiosarcoma 
are  only  moderately  malignant,  but  alveolar  and  melanotic 
forms  occur  which  are  highly  malignant.  Angiosarcoma 
may  arise  in  the  skin,  in  a  serous  membrane,  and  in  a  sali- 
vary gland. 

8.  Cylindroma,  or  Plexiforni  Sarcoma. — In  this  variety  the 
cells  adjacent  to  vessels  have  undergone  hyaline  or  myxo- 
matous degeneration ;  the  cells  distant  from  vessels  are  un- 
changed. Section  shows  the  normal  cells  apparently  con- 
tained in  spaces  with  hyaline  walls.  These  degenerative 
changes  occur  most  often  in  the  angiosarcomata.  Cylindro- 
mata  arise  from  the  brain,  saHvary  glands,  lachrymal  glands, 
and  rarely  from  the  subcutaneous  tissue.  The  growths  are 
only  moderately  malignant.^ 

9.  Mixed  tumors  consist  partly  of  mature  and  partly  of 
embryonic  tissue,  the  cellular  elements  exceeding  the  adult 
elements  in  amount.  Among  these  mixed  tumors  are  fibro- 
sarcoma or  the  recurrent  fibroid  tumor,  myxosarcoma, 
chondrosarcoma,  gliosarcoma,  and  osteosarcoma. 

10.  Endotheliomata  are  tumors  springing  from  endothe- 
lium. In  appearance  an  endothelioma  strongly  resembles 
cancer,  and  such  a  growth  is  often  spoken  of  as  endothelial 
cancer.  It  springs  from  endothelium,  however,  and  is  one 
of  the  connective-tissue  tumors,  and  should  be  regarded  as 
a  sarcoma.  Such  growths  can  arise  in  many  different  situa- 
tions, but  are  particularly  common  in  the  peritoneum,  pleural 
membrane,  membranes  of  the  brain,  ovary,  and  testicle.  The 
proliferating  endothelial  cells  lie  in  lymph-spaces,  and  the 
disease  probably  begins  in  the  endothelium  of  these  spaces, 
Endotheliomata  grow  rapidly  and  metastases  are  apt  to  pass 
to  the  serous  membranes.  In  the  brain  and  cord  endothe- 
lioma may  produce  no  symptoms  for  a  long  time.  It  is  not 
possible,  cHnically,  to  distinctly  recognize  endotheliomata 
from  ordinary  sarcomata. 

11.  Mycosis  ftingoides  is  a  disease  which  resembles  sar- 
coma in  many  particulars  and  may  be  a  form  of  sarcoma. 
It  attacks  the  skin  and  subcutaneous  tissues.     The  skin  at 

1  Stengel  :    Text-book  of  Pathology. 


MALIGXANT  COXXECTIVE-TISSUE    TUMORS.  289 

first  becomes  red  and  swollen;  nunierous  nodules  form  ;  the 
nodules  become  distinct  tumors,  soften  at  their  centers,  and 
fungation  occurs.  Microscopically  the  tumor  resembles  a 
lymphadenoma.  Mycosis  fungoides  is  considered  by  some 
pathologists  to  be  multiple  cutaneous  sarcoma. 

Treatment  of  Sarcomata. — Remove  a  sarcoma  at  once 
if  it  is  in  an  accessible  spot.  Never  delay  removal.  Cut 
well  clear  of  it.  If  affecting  a  part  where  amputation  is  im- 
possible, the  rapidly  growing  sarcomata  will  almost  inevitably 
return,  and  the  very  malignant  variety,  if  uninterfered  with, 
may  terminate  life  in  six  months  ;  but  even  in  such  case  oper- 
ation postpones  the  evil  day  and  renders  it  possible  that  death 
will  occur  from  metastatic  growth  in  an  organ,  and  that  the 
patient  will  escape  the  horrors  of  ulceration  and  hemorrhage 
from  the  original  tumor.  Slowh'  growing  and  hard  tumors 
offer  some  prospects  of  cure.  The  mixed  tumor  (as  a  recur- 
rent fibroid)  may  repeatedly  recur,  and  yet  the  patient  ma}'  be 
cured  at  last  by  a  sixth,  an  eighth,  or  a  tenth  operation.  In 
sarcoma  of  a  long  bone  amputation  should,  as  a  rule,  be 
performed,  though  in  some  cases  of  giant-celled  sarcoma 
of  the  radius,  ulna,  or  fibula  excision  may  be  employed. 
In  sarcoma  of  either  jaw-bone,  excision ;  of  the  eye,  enu- 
cleation ;  and  of  the  testicle,  castration,  is  demanded.  Sar- 
coma of  the  ovary  in  adults  demands  removal,  but  in 
children  the  operation  is  generally  useless.  Sarcoma  of 
the  kidney  in  adults  calls  for  nephrectomy,  but  in  chil- 
dren the  operation  is  usually  of  little  avail.  In  melanotic 
sarcoma  remove  the  growth  and  adjacent  lymph-glands, 
or  in  some  cases  amputate.  Removal  of  a  sarcoma  when 
there  is  no  hope  of  a  cure  is  often  justifiable  to  prolong 
life,  to  relieve  the  patient  of  a  foul,  offensive,  bleeding  mass, 
and  to  permit  of  an  easier  road  to  death  by  means  of 
metastasis  to  an  internal  organ.  In  an  inoperable  case  the 
ligation  of  the  vessel  of  supply  may  do  good.  In  sarcoma 
of  the  tonsil  Dawbarn  advises  the  extirpation  of  the  external 
carotid  artery  and  the  ligation  of  its  branches.  The  opera- 
tion is  performed  first  on  one  side  of  the  tumor  and  in  a 
week  or  so  on  the  other  side.  I  emplo}'ed  it  in  one  case 
with  distinct  benefit.  Wright  advocates  internal  treatment 
for  sarcoma  and  for  cancer.  He  advises  that  bromid  of 
arsenic  be  given  for  a  long  period  of  time,  the  dose  being 
gr.  jlg-  to  gr.  jL  after  each  meal.  Before  meals  gr.  x  of  car- 
bonate of  lime  are  advised.  This  treatment,  Wright  holds, 
should  be  used  before,  and  for  many  months  after,  opera- 
tion, as  an  aid  to  surger}\     In  inoperable  cases  it  ma}-  be 

19 


290  TUMORS   OR  MORBID    GROWTHS. 

tried.^  Occasionally,  though  very  rarely,  suppuration  cures 
a  sarcoma.  Wyeth,  of  New  York,  reported  a  case  of  sar- 
coma of  the  abdominal  wall.  It  was  found  possible  to 
remove  only  part  of  the  growth ;  suppuration  followed  and 
the  tumor  disappeared,  and  ten  years  later  had  not  returned. 
It  has  been  observed  that  an  attack  of  erysipelas  occa- 
sionally greatly  benefits  a  sarcoma,  causing  large  masses  of 
the  growth  to  soften  or  to  slough  and  exposing  a  granulating 
surface.  Busch  noticed  this  in  1866,  but  the  fact  had  been 
observed  in  the  seventeenth  century.  Interest  was  decidedly 
awakened  by  Billroth's  case  of  sarcoma  of  the  pharynx  which 
was  cured  by  an  attack  of  facial  erysipelas.  It  was  suggested 
that  in  inoperable  cases  of  sarcoma  erysipelas  might  be 
established  artificially.  Fehleisen  inoculated  tumors  with 
cultures  of  erysipelas.  Lassar,  in  1891,  employed  the  toxins 
(cultures  rendered  sterile  by  heat  and  filtration).  In  1892 
Coley  began  his  observations.  The  first  plan  was  as  follows  : 
a  bouillon-culture  is  made  of  the  streptococci ;  this  culture 
is  filtered  through  porcelain  and  an  injection  is  given  once  a 
day  into  and  about  the  sarcoma.  The  first  dose  is  ITLx,  and 
it  is  progressively  increased ;  it  should  cause  a  febrile  reac- 
tion, and  sometimes  establishes  softening  or  suppuration. 
Coley's  present  method  is  as  follows  :  make  cultures  of  ery- 
sipelas cocci  in  cacao-broth ;  after  three  weeks  inoculate 
them  with  the  bacillus  prodigiosus,  and  cultivate  the 
mixed  growth  for  four  weeks.  The  mixed  cultures  are  main- 
tained at  136°  F.  until  they  become  sterile.  This  sterile 
fluid  contains  the  toxins.  The  dose  is  from  i  to  8  minims. 
The  material  is  very  powerful  and  may  cause  high  fever. 
Begin  with  a  small  dose  and  gradually  increase  until  the 
proper  amount  of  reaction  ensues  (i03°-i04°  P.).  The 
injection  may  be  about  the  sarcoma  or  at  a  distant  point. 
It  seems  definitely  proved  that  cases  are  occasionally 
cured  by  Coley's  fluid.  Spindle-celled  sarcomata  are 
influenced  most  favorably.  Round-celled  sarcomata  are 
very  refractory  and  so  are  cancers.  The  method  is  not 
entirely  free  from  danger.  Emmerich  and  SchoU  claim  good 
results  from  the  injection  of  erysipelas  serum.  A  sheep  is 
injected  with  cultures  of  erysipelas,  the  blood  is  drawn,  the 
serum  separated,  filtered  to  remove  cocci,  and  injected  about 
the  sarcoma.  Results  are  not  definite.  Among  other  agents 
which  have  been  used  to  inject  inoperable  sarcomata  we  may 
mention  alcohol,  chlorid  of  zinc,  arsenic,  corrosive  subli- 
mate, thiosinnamin,  pepsin,  alkalies,  etc.     The  injection  of 

1  Annals  of  Stirgery,  April,  1893. 


PAriLLOMAT.-U    OR    WARTS.  29 1 

anilin-products  into  the  sarcoma,  which  has  received  a  quaU- 
fied  commendation  from  some  observers,  has  been  aban- 
doned by  most  surgeons. 

Innocent  Bpithelial  Tumors. — These  growths  imi- 
tate an  epithelial  tissue  of  the  mature  and  healthy  organ- 
ism. 

Papillomata,  or  Warts. — Papillomata  are  formed  upon 
the  type  of  cutaneous  and  mucous  papillae.  A  papilloma 
consists  of  a  fibrous  stroma  which  contains  blood-vessels  and 
lymphatics  and  is  covered  with  epithelium  of  the  variety 
appertaining  to  the  diseased  part.  Papillomata  grow  from 
the  skin  and  from  mucous  membranes ;  they  may  be  single 
or  multiple ;  many  may  form  in  one  region  or  various  dis- 
tant parts  may  be  affected ;  they  may  be  painless  or  may  be 
ulcerated  or  bleeding ;  they  vary  in  color  from  light  pink  to 
deep  brown  or  black.  Papillomata  of  the  skin  are  usually 
hard ;  papillomata  of  mucous  membranes  are  soft.  A  skin 
wart  may  be  smooth  and  rounded,  or  may  look  like  a  cauli- 
flower, the  epidermis  upon  it  being  very  rough.  A  papilloma 
of  a  mucous  membrane  looks  like  a  cauliflower.  Papillomatous 
masses  may  gather  around  the  anus,  the  vagina,  or  the  penis 
during  the  existence  of  a  filthy  discharge  (venereal  warts),  and 
crops  of  warts  may  appear  on  the  hands  of  those  who  work  in 
irritant  material  (as  petroleum).  Papillomata  are  apt  to  arise 
in  mucous  membranes  about  carcinomata  or  chronic  ulcera- 
tions. A  large  crop  of  warts  may  disappear  in  a  single  night ; 
hence  the  popular  belief  in  the  efficacy  of  charms.  Warts 
are  particularly  common  on  the  skin  of  the  back  of  the  hands 
and  fingers,  the  skin  of  the  back,  and  the  skin  of  the  neck 
and  scalp.  A  single  skin-wart  may  reach  the  size  of  a  walnut 
and  become  pigmented.  The  squamous  epithelium  covering 
a  skin-wart  may  become  horny  (a  wart-horn).  Other  cu- 
taneous horns  arise  from  the  nails,  from  the  scars  of  burns, 
or  from  ruptured  sebaceous  cj^sts. 

Villous  papillomata  grow  chiefly  from  the  bladder,  but  they 
may  also  grow  from  the  stomach  and  intestine.  A  papilloma  of 
mucous  membrane  covered  with  squamous  epitheHum  looks 
like  a  wart  of  the  skin.  Papillomata  of  the  larynx  are 
formed  of  squamous  epitheHum.  Villous  papillomata  form 
tufts  like  the  villous  processes  of  the  chorion  ;  they  may  be 
single  or  multiple,  and  may  be  sessile  or  pedunculated ;  they 
are  very  vascular,  and  are  apt  to  bleed  freely.  Papillomata 
may  arise  in  cysts  of  the  paroophoron,  in  cysts  of  the  mam- 
mary gland,  from  the  choroid  plexuses  of  the  ventricles  of 
the    brain,  and  from  the  spinal    membranes.      Papillomata 


292  TUMORS    OR   MORBID    GROWTHS. 

may  give  rise  to  hemorrhage  or  may  impair  the  function  of 
a  part.     Any  papilloma  may  become  a  cancer. 

Treatment. — Venereal  warts  are  treated  by  repeatedly 
washing  with  peroxid  of  hydrogen,  drying  with  cotton,  and 
dusting  with  a  powder  composed  of  borated  talcum  or  of 
equal  parts  of  calomel  and  subnitrate  of  bismuth,  or  of  oxid 
of  zinc  and  iodoform.  If  they  do  not  soon  dry  up,  cut  them 
ofTwith  scissors  and  burn  with  the  Paquelin  cautery.  Ordinary 
warts  may  usually  be  destroyed  in  a  short  time  by  daily  ap- 
plications of  lactic  or  chromic  acid.  In  multiple  warts  of 
the  face  Kaposi  applies  daily  for  several  days  a  portion  of 
the  following  combination  :  sublimed  sulphur,  35  ;  glycerin, 
'i^\\\  acetic  acid,  o2|.  Keeping  a  wart  constantly  moist 
with  castor  oil  will  often  cause  it  to  drop  off.  Warts,  and 
even  extensive  callosities,  may  be  removed  by  painting  once 
a  day  for  five  days  with  pure  carbolic  acid  and  covering  with 
lint  kept  wet  with  boric  acid.  A  convenient  plan  is  to  paint 
a  wart  daily  with  a  solution  containing  i  part  of  corrosive 
sublimate  to  30  parts  of  collodion  (hydrarg.  chlor.  corros., 
Z\\  collodion,  31 S)-  Large  warts  should  be  excised.  Vil- 
lous papillomata  of  the  bladder  demand  the  performance  of 
a  suprapubic  cystotomy  in  order  to  remove  them.  A 
papilloma  of  the  larynx  may  be  removed  with  the  cautery 
loop  or  may  be  destroyed  with  the  cautery. 

Adenomata. — Adenomata  are  tumors  corresponding  in 
structure  to  normal  epithelial  glands.  They  have  a  frame- 
work of  vascular  connective  tissue,  and  they  may  contain  acini 
and  ducts  like  racemose  glands  or  tubes  like  tubular  glands. 
The  acini  or  tubules  contain  epithelium  of  either  the  cylin- 
drical or  polyhedral  variety.  Adenomata  grow  from  secret- 
ing glands,  but  cannot  produce  the  secretion  of  the  glands 
from  which  they  spring  ;  or,  if  they  do  secrete,  the  fluid  is 
retained,  and  not  discharged  by  the  gland-ducts.  Adenomata 
occur  in  the  mammary  gland,  the  parotid,  the  ovary,  the 
thyroid  gland,  the  liver,  the  sweat-glands,  the  sebaceous 
glands,  the  kidney,  the  pylorus,  and  the  prostate ;  and  they 
may  spring  as  pedunculated  growths  from  the  mucous  lining 
of  the  intestine  and  uterus.  They  are  encapsuled,  are  usually 
single,  but  may  be  multiple,  are  of  slow  growth,  but  may 
attain  a  great  size  ;  they  do  not  tend  to  recur  after  thorough 
removal,  do  not  involve  adjacent  glands,  and  do  not  dis- 
seminate ;  they  are  firm  to  the  touch ;  they  tend  to  become 
cystic  (especially  in  the  thyroid),  the  fluid  which  distends 
the  ducts  being  due  to  mucoid  liquefaction  of  the  proliferat- 
ing epithelium.     If  cysts  form,  the  growth  is  spoken  of  as  a 


MALIGNANT  EPITHELIAL    TUMORS.  293 

cvstic  adenoma.  If  the  framework  of  an  adenoma  contains 
considerable  fibrous  tissue,  the  tumor  is  named  a  fibro- 
adenoma. Adenomata  are  particular!)-  liable  to  become 
carcinomatous. 

In  the  breast  a  fibro-adenoma  has  a  distinct  capsule ;  it  is 
elastic  and  movable,  is  usually  superficial,  and  one  occasion- 
ally exists  in  each  gland,  they  are  most  common  before 
the  age  of  thirty,  and  are  often  painful,  especially  during 
menstruation.  Cystic  adenomata  of  the  breast  attain  a  large 
size ;  they  are  en'capsuled  and  grow  slowly,  are  most  com- 
mon after  the  thirtieth  year,  and  are  rarely  painful.  Both 
fibro-adenoma  and  cy.stic  adenoma  may  arise  in  the  male 
breast.  Young  unmarried  women  not  unusually  develop 
in  the  breast  small,  very  tender,  and  painful  bodies,  most 
usually  around  the  edge  of  the  areola,  which  bodies  increase 
in  size  and  become  more  tender  during  menstruation  ;  they 
are  only  c}^sts  of  the  mammary  tissue. 

Adenomata  of  the  thyroid  gland  begin  before  the  fifteenth 
year.  Adenomata  may  arise  in  the  prostate  if  that  gland  be 
already  the  seat  of  senile  hypertrophy.  Adenomata  of  mu- 
cous glands  may  arise  in  the  young  or  middle-aged.  Adeno- 
mata of  mucous  membranes  often  cause  hemorrhage  and 
interfere  with  function. 

Treatment. — Adenomata  should  be  extirpated.  To  leave 
them  alone  exposes  the  patient  to  the  danger  of  cancerous 
change.  By  confusing  adenomata  of  the  mammary  gland 
with  small  'cysts  of  that  structure  an  erroneous  belief  has 
arisen  that  the  former,  as  well  as  the  latter,  may  sometimes 
be  cured  by  the  local  use  of  iodin,  mercury,  ichthyol,  and 
the  internal  use  of  iodid  of  potassium.  The  treatment  in 
the  breast,  as  elsewhere,  is  excision. 

Malignant  Epithelial  Tumors,  Carcinomata,  or 
Cancers. — Cancers  are  tumors  growing  from  epithelial  sur- 
faces, and  are  composed  of  embryonic  epithelial  cells  which 
are  clustered  in  spaces,  nests,  or  alveoli  of  fibrous  tissue  and 
which  proliferate  enormously,  extending  beyond  normal  ana- 
tomical boundaries  and  as  an  invading  host  entering  into 
connective  tissues.  The  cells  of  a  cluster  are  not  separated 
b\'  any  stroma,  and  the  w^alls  of  the  alveoli  carry  blood-ves- 
sels and  lymphatics.  The  growth  may  be  cancerous  from 
the  start,' or  ma}'  have  begun  as  an  innocent  epithehal 
tumor.  Cancers 'are  always  derived  from  epithelium  (of 
glands,  of  skin,  of  mucous'  membrane,  etc.),  and  if  found  in 
a  non-epithelial  tissue  must  be  secondary,  or  must  have 
arisen  from  a  depot  of  embryonal  epithelial  cells  of  prenatal 


294  TUMORS   OR   MORBID    GROWTHS. 

origin  lying  in  the  midst  of  a  non-epithelial  tissue.  Carcino- 
mata  have  no  capsules,  rapidly  infiltrate  surrounding  tissues, 
and  are  firmly  anchored  and  immovable.  In  the  beginning  a 
cancer  is  a  local  lesion  ;  but  it  soon  attacks  related  lymph- 
glands  and  by  means  of  the  lymph,  and  very  rarely  by  the 
blood  (Thiersch  and  Waldeyer),  is  disseminated  throughout 
the  system,  secondary  growths  arising  which  are  identical 
with  the  parent  growth.  Cancer  is  rare  before  the  age  of 
forty,  and  never  occurs  before  puberty ;  and  is  sometimes 
linked  with  continued  irritation  as  a  cause  (cancer  of  the  penis 
in  phimosis  ;  cancer  of  the  lip  from  the  hot  stem  of  a  clay 
pipe  ;  chimney-sweeps'  cancer  from  soot  in  the  scrotal  folds  ; 
cancer  of  the  gall-bladder  when  gall-stones  exist).  Dennis 
says  that  all  clinical  evidence  points  strongly  to  the  view 
that  inflammatory  changes  following  irritation  are  responsible 
for  cancer.  Hereditary  influence  seems  in  some  instances  to 
favor  the  development  of  carcinoma.  The  weight  of  opinion 
is  opposed  to  the  theory  that  cancer  is  of  parasitic  origin. 
Tillmanns  says  that  the  presence  of  protozoa  has  never  been 
proved.^  The  same  author  says  that  transplantation  has 
taken  place,  but  only  by  auto-infection  or  by  transplantation 
to  an  animal  of  the  same  species.  The  facts  that  transplan- 
tation can  be  sometimes  carried  out,  and  that  contagion  is  a 
possible  occurrence  under  exceptional  circumstances,  do  not 
prove  that  cancer  is  a  parasitic  disease,  but  simply  prove  that 
it  can  be  transplanted.  It  is  not  that  the  cancer  carries  a  para- 
site which  will  cause  the  disease  in  sound  tissues,  but  rather 
thatthecellsof  the  cancer  may  themselves  take  root  and  grow 
in  sound  tissues  (p.  266).  A  carcinoma  is  often  the  seat 
of  pricking  pain  ;  the  growth  tends  strongly  to  recur  after 
removal ;  is  prone  to  ulcerate,  causing  pain,  hemorrhage,  and 
cachexia ;  makes  rapid  progress,  and  is  often  fatal  in  from 
one  to  two  and  a  half  years.  It  is  more  common  in  women 
than  in  men,  and  rarely  exists  in  association  with  tubercle. 
After  a  cancer  has  existed  for  a  time  in  an  important  struct- 
ure, or  after  a  superficial  cancer  has  ulcerated  and  become 
hemorrhagic,  there  are  noted  in  the  individual  evidences  of  ill- 
ness and  exhaustion.  We  speak  of  this  condition  as  the 
"  cancerous  cachexia,"  and  in  it  the  muscles  are  wasted,  the 
body-weight  is  constantly  diminishing,  the  complexion  is  sal- 
low, the  face  is  sunken,  pearly  white  conjunctivae  contrast 
strongly  with  the  yellow  skin,  the  pulse  is  weak  and  rapid, 
and  night-sweats  add  to  the  exhaustion.     The  above  condi- 

1  Verhandiimgen  der  deutscheit  Gesellschaft  fiir  Chh-tirgie,  XXIV.  Kongress, 
1895. 


.y.lLIGX.-lA'T  EPITHELIAL    TCMOHS.  295 

tion  is  due  to  the  absorption  of  toxic  products  from  the  dis- 
eased tissues,  and  also  to  pain,  loss  of  sleep,  bleeding,  de- 
privation of  exercise,  malassimilation  of  food,  and  anxiet}^ 
Cancer  may  kill  b}-  obstructing  a  canal,  by  destro}-ing  the 
functions  of  a  viscus  or  organ,  by  hemorrhage,  by  anemia,  by 
sepsis,  or  by  exhaustion.  The  death-rate  from  cancer  in- 
creases year  by  year.  It  is  pointed  out  by  W.  Roger  WiHiams 
that  in  England  and  Wales  the  mortality  from  cancer  has 
increased  from  i  to  5646  in  1840  to  i  to  1306  in  1896,  and 
the  proportion  to  deaths  from  other  causes  has  risen  from  i 
to  129  in  1840  to  I  to  22  in  1896.^  The  cause  of  this 
increase  is  doubtful,  but  the  fact  is  alarming. 

Classification  of  Carcinomata. — Carcinomata  are  classi- 
fied as  follows  :  I.  Epithelioma;  2.  Rodent  ulcer,  or  Jacob's 
ulcer ;  3.  Spheroidal-celled  cancer  {a,  scirrhus ;  b,  encepha- 
loid  ;  c,  colloid)  ;  and  4.  Cylindrical-celled  cancer. 

EpitJidio))iata. — An  epithelioma  arises  from  surface  epi- 
thelium, and  may  arise  from  squamous  cells  or  cylindrical 
cells,  according  to  the  location. 

Sqiiai)ious-ccllcd  cpitliclioma  takes  origin  from  the  skin 
or  from  a  mucous  membrane  covered  with  pavement-epi- 
thelium. It  is  especialh'  apt  to  appear  at  the  junctions  of 
skin  and  mucous  membrane  (as  the  lips)  or  the  point  of 
juxtaposition  of  different  kinds  of  epithelium.  These 
growths  arise  in  the  anus,  vagina,  penis,  scrotum,  lips, 
tongue,  mouth,  nose,  and  other  situations.  There  is  an  in- 
growth of  surface-epithelium  into  the  subepithelial  connec- 
tive tissue,  colonies  of  cells  growing  inward  and  formino- 
epithelial  nests.  It  may  arise  without  discoverable  cause,  it 
may  follow  prolonged  irritation,  or  it  may  arise  in  a  wart  or 
fissure.  In  the  nipple  it  is  not  ven,'  unusually,  and  in  the 
scrotum  and  nose  it  is  occasionally,  preceded  by  a  persistent 
eczema,  due  possibly  to  psorosperms,  and  known  as  Pagcfs 
disease.  Paget's  disease  is  not  a  true  eczema,  but  is  rather  a 
malignant  dermatitis.  A  crust  gathers  on  the  part,  and  beneath 
this  crust  is  a  raw,  red,  and  moist  surface,  the  edge  of  which 
is  slightly  elevated  and  somewhat  indurated.  In  the  begin- 
ning there  is  a  strong  resemblance  to  eczema.  The  nipple 
is  apt  to  retract.  The  parts  are  the  seat  of  a  constant  itch- 
ing and  scalding  sensation.  The  area  may  become  cancerous 
in  a  few  weeks,  but  may  not  for  }-ears.  Squamous  epithe- 
lioma generally  begins  as  a  wart}"  proturberance  which  soon 
ulcerates.  The  malignant  ulcer  has  a  hard,  irregular  base, 
uneven   edges,  a  foul,  fungous-like  bottom,  and  gives  off  a 

^  Lancet^  Aug.  20,  1898. 


296  TUMORS   OR   MORBID    GROWTHS. 

sanious  or  ichorous  discharge.  This  ulcer  is  the  seat  of 
sharp,  pricking  pain,  sometimes  bleeds,  and  extends  over  a 
considerable  area,  embracing  and  destroying  every  structure. 
Epithelioma  affects  lymphatic  glands  usually  early,  but  such 
infection  may  be  delayed  for  eight  or  ten  months.  Epithe- 
liomatous  glands  break  down  in  ulceration,  making  frightful 
gaps  and  often  causing  fatal  hemorrhage.  Dissemination  is 
not  nearly  so  common  as  in  other  forms  of  cancer,  but  it 
does  sometimes  occur. 

Cylindrical-celled  EpitJiclioma. — This  form  of  growth  takes 
origin  from  structures  covered  with  or  containing  cylindrical 
epithelium,  and  it  contains  cylindrical  or  columnar  cells.  It 
is  composed  of  a  stroma  of  fibers  between  which  lie  tubular 
glands  lined  with  columnar  epithelium  and  containing  masses 
of  epithelial  cells.  Such  tumors  are  found  in  the  uterus  and 
gastro-intestinal  tract,  and  may  begin  from  the  surface  epi- 
thelium or  from  the  cells  of  tubular  glands.  In  these  tumors 
there  is  an  acinus-like  structure  and  the  spaces  are  filled  with 
proliferating  epithelium.  Cylindrical-celled  cancers  also  arise 
from  the  mammary  gland,  liver,  and  kidney.  One  of  the 
most  common  seats  of  cylindrical  cancer  is  the  rectum. 
Cancer  of  the  rectum  may  occur  at  an  earlier  age  than 
cancer  elsewhere,  being  not  uncommon  between  the  ages 
of  twenty-eight  and  forty.  Cylindrical-celled  epitheliomata 
are  at  first  covered  with  mucous  membrane,  but  they  soon' 
ulcerate  and  involve  the  submucous  and  muscular  coats 
in  the  growth.  They  grow  rather  slowly,  usually  but 
not  always  cause  lymphatic  involvement,  and  finally  dis- 
seminate widely.  They  require  often  from  five  to  six  years 
to  cause  death. 

A  rodent  or  Jacob's  ulcer  is  scarcely  ever  met  with  except 
upon  the  face,  though  Jonathan  Hutchinson  saw  one  upon  the 
forearm,  and  James  Berry  met  with  one  upon  the  arm.  It  is 
especially  common  upon  the  nose  and  forehead.  It  begins 
after  the  age  of  forty  as  a  little  warty  prominence  which 
ulcerates  in  the  center,  the  ulceration  progressing  at  a  rate 
equal  to  the  new  growth.  The  ulcer  becomes  deep ;  it  is 
not  crusted ;  its  edges  are  irregular,  hard,  and  everted ;  the 
floor  is  smooth  and  of  a  grayish  color ;  the  discharge  is  thin 
and  acrid;  and  the  parts  about  the  sore  contain  numbers  of 
visible  vessels.  Jacob's  ulcer  grows  slowly,  may  last  for 
years,  does  not  involve  the  lymphatics,  produces  no  consti- 
tutional cachexia,  and  is  rarely  fatal.  A  rodent  ulcer  is 
usually  considered  to  be  a  malignant  epithelial  growth  which 
springs   from  a  sweat-gland,  a  sebaceous  gland,  or  a  hair- 


MALIGNANT  RriTHF.LIAL    TUMORS.  297 

follicle,  but  Kanthack  asserts  that  before  ulceration  the  rete 
and  the  sweat-glands  are  normal,  but  the  sebaceous  glands 
are  destroyed.  The  base  and  edges  of  the  ulcer  are  hard, 
which  differentiates  it  from  lupus ;  and,  further,  the  bacilli  of 
tubercle  may  sometimes  be  cultivated  from  the  discharge  of 
an  area  of  lupus  (p.  194).  Rodent  ulcer  begins  below  the 
skin,  ordinary  epithelioma  begins  in  the  skin  (Butlin),  and  a 
rodent  ulcer  contains  no  cell-nests. 

Glandzilar  Carcinoma. — Glandular  carcinomata  in  structure 
resemble  racemose  glands.  They  consist  of  a  stroma  of 
connective  tissue  and  alveoli  filled  with  proliferating  epithe- 
lial cells.  If  the  proportion  between  the  fibrous  stroma 
and  the  cellular  elements  is  about  the  same  as  in  a  normal 
gland,  the  growth  is  called  simple.  When  the  cellular 
element  is  in  excess  the  growth  is  soft  (medullary),  and 
when  the  fibrous  stroma  is  in  excess  the  growth  is  hard 
(scirrhus). 

1.  Scin'Jioiis  carcinoma  is  a  white  and  fibrous  mass 
which  has  no  capsule,  which  infiltrates  tissues,  and  which 
draws  in  toward  it,  by  the  contraction  of  its  outlying  fibrous 
processes,  adjacent  soft  parts,  thus  producing  dimpling,  or, 
as  in  the  breast,  retraction  of  the  nipple.  It  is  composed 
of  spheroidal  cells  in  alveoli  formed  of  connective-tissue 
bands.  The  commonest  seat  of  scirrhus  is  the  female  breast. 
It  occurs  also  in  the  skin,  vagina,  rectum,  prostate,  uterus, 
stomach,  and  esophagus.  It  is  most  frequent  in  Avomen 
after  forty.  It  begins  as  a  hard  lump  which  is  at  first  pain- 
less, but  which  after  a  time  becomes  the  seat  of  an  acute, 
localized,  pricking  pain.  This  lump  grows  and  becomes 
irregular  and  adherent,  causing  puckering  of  the  soft  parts. 
After  the  skin  or  mucous  membrane  above  it  has  become 
infiltrated  ulceration  takes  place  and  a  fungous  mass  pro- 
trudes Avhich  bleeds  and  suppurates.  The  adjacent  lymphatic 
glands  usually  become  cancerous,  the  time  occupied  being 
from  six  to  ten  weeks,  and  constitutional  involvement  is  rapid 
and  certain. 

2.  Mcdnllary  or  cnceplialoid  carcinoma  is  a  soft  gray  or 
brain-like  mass.  It  is  a  rare  growth,  it  has  no  capsule,  and 
it  may  appear  in  the  kidney,  liver,  ovary,  testicle,  mammaiy 
gland,  stomach,  bladder,  and  maxillary  antrum.  An 
encephaloid  cancer  often  contains  cavities  filled  with  blood, 
and  this  variety  is  known  as  a*  "  hematoid  "  or  a  "telangiec- 
tatic "  carcinoma.  These  growths  are  soft  and  semi-fluctuat- 
ing, they  infiltrate  rapidly  and  soon  fungate,  and  the)^ 
terminate  life  in  from  a  year  to  a  year  and  a  half     If  the 


298  TUMORS   OR  MORBID    GROWTHS. 

cells  of  encephaloid  become  filled  with  melanin,  the  condition 
is  called  "melanosis"  or  "melanotic  cancer." 

3.  Colloid  cancer  is  extremely  rare.  It  arises  from  either 
a  scirrhus  or  encephaloid,  when  the  cells  or  the  stroma  of 
such  a  growth  undergo  colloid  degeneration.  On  section 
there  will  be  seen  in  the  center  of  the  growth  a  series  of 
cavities  filled  with  a  material  resembling  honey  or  jelly ;  the 
periphery  is  frequently  an  ordinary  scirrhus  or  encephaloid 
cancer.  Colloid  degeneration  is  most  prone  to  attack  carci- 
nomata  of  the  stomach,  mammary  gland,  and  intestine.  The 
name  colloid  cancer  is  often  given  to  glistening,  gelatinous, 
malignant  growths  springing  from  the  ovary,  testicle,  mam- 
mary gland,  or  gastro-intestinal  tract.  The  condition  is  due 
to  mucous  degeneration  of  the  connective  tissue  or  of  the 
epithelial  tissue  of  a  carcinoma.  Only  a  portion  of  the  tumor 
may  degenerate  or  the  entire  mass  may  become  gelatinous. 

Syncytioma  Maligimvi. — By  this  name  is  meant  a 
malignant  epithelial  growth  arising  from  the  site  of  the 
placenta  during  pregnancy  or  the  puerperal  state.  It 
resembles  placenta  in  appearance  and  rapidly  causes  metas- 
tases by  way  of  the  blood-vessels.     It  is  quickly  fatal. 

Treatment. — Carcinomata  demand  early  and  free  excision, 
with  removal  of  implicated  glands.  Anatomically  related 
lymph-nodes  must  be  removed  even  if  they  show  no 
evidence  of  involvement.  If  operation  is  early  and  thorough, 
and  if  certain  regions  are  involved,  a  considerable  proportion 
of  cases  can  be  cured.  Carcinomata  of  the  lip,  the  skin,  and 
the  mammary  gland  can  often  be  cured.  A  recurrent  growth 
may  be  removed  as  a  palliative  measure,  to  lessen  pain 
and  to  relieve  the  patient  from  ulceration  and  hemorrhage, 
but  such  an  operation  is  rarely  curative.  If  a  growth  does 
not  recur  within  five  years  after  removal,  a  cure  has  probably 
been  attained ;  in  fact,  if  there  is  no  recurrence  within  three 
years,  the  case  is  probably  cured.  The  three-year  limit  has 
been  usually  accepted  since  Volkmann's  paper  on  the  subject. 
A  rodent  ulcer  should  be  excised  or  else  be  curetted  and 
cauterized  with  the  hot  iron  or  the  Paquelin  cautery.  In 
cancer  of  the  lower  lip,  remove  the  growth  by  the  incision 
shown  on  page  747,  or  by  a  V-shaped  incision,  or  cut  away 
the  entire  lip.  In  every  case  remove  the  glands  beneath  the 
jaw.  In  cancer  of  the  tongue,  excise  this  organ  and  also  the 
lymph-nodes  from  beneath  the  jaw  and  in  the  anterior  carotid 
triangles.  In  cancer  of  the  breast,  remove  the  breast,  the 
pectoral  fascia,  and  the  great  pectoral  muscle,  and  take 
away  the    fat  and    glands  of  the   axilla.     In  cancer  of  the 


CYSTS.  299 

rectum,  if  near  the  surface,  excise  the  rectum  from  below ;  if 
above  five  inches  from  the  anus,  do  the  sacral  resection  of 
Kraske  and  then  remove  the  growth.  In  cancer  of  the 
csopJiagiis,  perform  gastrostomy ;  in  cancer  of  the  pylorus, 
perform  pylorectomy  or  gastro-enterostomy ;  in  cancer  of 
the  bozvcl,  do  resection  with  end-to-end  approximation,  side- 
track the  diseased  area  by  an  anastomosis,  or  make  an 
artificial  anus  ;  in  cancer  of  the  penis,  amputate  and  remove 
the  glands  of  the  groin.  Erysipelas  toxins  and  erysipelas 
serum  have  been  tried  in  inoperable  carcinoma,  but  without 
any  positive  benefit.  The  same  is  true  of  pyoktanin,  thiosin- 
namin,  and  of  all  other  drugs  that  have  been  suggested.  In 
some  cases  ligation  of  the  artery  of  supply  or  extirpation  of 
the  artery,  as  suggested  by  Dawbarn,  retards  growth.  In 
cancer  of  the  breast,  oophectomy  occasionally  produces 
benefit  or  even  cure  (Beatson's  operation).  In  inoperable 
cases  palliative  operations  may  be  justifiable  to  relieve  some 
urgent  discomfort  or  get  rid  of  a  foul  or  bleeding  mass. 
Gastro-enterostomy,  gastrostomy,  and  colostomy  are  pallia- 
tive operations.  In  a  malignant  growth  of  the  nasopharynx 
tracheotomy  may  be  required,  and  in  a  malignant  growth  of 
the  neck  of  the  bladder  it  may  be  advisable  to  perform 
suprapubic  cystotomy.  In  an  inoperable  case  relieve  the 
pain  by  opium,  giving  as  much  as  may  be  required  to  secure 
ease.  Opium  so  used  seems  not  only  to  relieve  pain,  but  to 
retard  the  growth  of  the  tumor  and  to  favor  the  development 
of  fibrous  tissue  in  the  stroma. 

Cysts. — A  cyst  is  a  sac  containing  a  fluid  or  a  semi-fluid. 

Division  of  Cysts. — Cysts  are  divided  into  (i)  Retention- 
cysts,  which  are  due  to  blocking  up  of  the  excretory  ducts 
of  glands  and  accumulation  of  the  glandular  secretions.  These 
comprise  sebaceous  cysts  or  wens,  serous  cysts,  mucous 
cysts,  salivary  cysts,  milk-cysts,  oil-cysts,  and  seminal  cysts. 
(2)  Exudation-cysts,  which  are  due  to  accumulations  in  closed 
cavities.  In  this  group  are  placed  synovial  cysts  (ganglions 
and  bursse).  Dentigerous  cysts  used  to  be  considered  under 
this  head.  (3)  Dermoid  cysts,  which  are  congenital  and 
arise  from  inversion  of  a  portion  of  the  epiblast  and  im- 
perfect closure  of  fetal  clefts.  (4)  Cystomas,  which  are  cysts 
of  new  formation  due  to  cystic  degeneration  of  connective 
tissue.  These  cysts  are  found  -ia- -the  neck  (hygroma)^  in. 
the  arm-pit,  and  in  the  perineum.  An  example  of  a  cys- 
toma is  found  in  the  bursa  which  develops  from  pressure. 
(5)  Extravasation-cysts ,  that  form  around  blood-extravasa- 
tions.    (6)  Hydatid  cysts,  or  cysts  due  to  the  echinococcus. 


300  TUMORS   OR   MORBID    GROWTHS. 

A  mother-cyst  is  formed,  which  becomes  filled  with  daughter- 
cysts  floating  in  a  saline  liquor  containing  hooklets. 

Sebaceous  cysts  arise  when  the  excretory  duct  of  a  seba- 
ceous gland  is  blocked  by  dirt  or  occluded  by  inflammation. 
The  orifice  of  the  duct  is  often  visible  as  a  black  speck  over 
the  center  of  the  cyst.  They  are  very  common  in  the  scalp, 
being  known  as  "  wens,"  and  upon  the  face,  neck,  shoulders, 
and  back.  Arising  in  the  skin,  and  not  under  it,  the  skin 
cannot  be  freely  moved  over  a  sebaceous  cyst.  A  sebaceous 
cyst  is  lined  with  epithelium  and  is  filled  with  foul-smelling 
sebaceous  material.  A  sebaceous  cyst  may  suppurate.  When 
a  cyst  ruptures  and  the  contents  become  hard,  a  horn  is 
formed.  The  other  form  of  horn  has  been  previously  alluded 
to  as  due  to  horny  transformation  of  a  wart. 

Treatment. — To  treat  a  sebaceous  cyst,  incise  the  portion 
of  skin  above  it,  and  dissect  the  sac  entirely  away  with  scis- 
sors or  a  dissector,  trying  not  to  rupture  the  delicate  wall. 
If  even  a  small  particle  of  the  wall  is  left,  the  cyst  will  reform. 
If  it  ruptures  during  removal  and  it  is  feared  that  some  por- 
tion may  remain,  paint  the  interior  of  the  wound  with  pure 
carbolic  acid.  If  acid  is  not  used,  close  without  drainage ; 
but  if  acid  is  used,  drain  for  twenty-four  hours.  If  an 
abscess  forms  in  a  sebaceous  cyst,  open  it,  grasp  the  edges 
of  the  cyst-lining  with  forceps,  dissect  out  this  lining  with 
scissors  curved  on  the  flat,  cauterize  with  pure  carbolic  acid, 
and  drain  for  twenty-four  hours. 

Dermoid,  cysts  are  lined  with  true  skin.  They  contain 
sebaceous  matter,  hair,  teeth,  or  other  epiblastic  products. 
They  are  always  congenital,  but  may  be  so  small  at  birth  as 
to  escape  notice  for  years.  They  may  be  distinguished  from 
sebaceous  cysts  by  the  fact  that  they  always  lie  below  the 
deep  fascia,  and  hence  the  skin  is  freely  movable  over  them. 
They  are  met  with  at  the  root  of  the  nojse,  at  the  orbital 
angles,  in  the  eyelids,  upon  the  floor  of  the  mouth,  over  the 
sacrum  or  coccyx,  and  in  the  ovaries,  the  testicle,  the  brain, 
the  eyes,  the  mediastinum,  the  lungs,  the  omentum,  the 
mesentery,  and  the  carotid  sheaths.  They  are  due  to  imper- 
fect closure  of  fetal  clefts  and  inclusion  of  epiblast.  If  a 
dermoid  cyst  contains  bones,  it  shows  that  mesoblast  was 
included  as  well  as  epiblast. 

Treatment. — To  treat  a  dermoid  cyst,  extirpate,  if  accessi- 
ble, in  the  same  manner  as  is  recommended  in  the  case  of 
a  sebaceous  cyst.  If  it  lies  over  bone,  carry  the  incision 
down  to  the  bone :  the  growth  will  be  found  adherent,  so 
remove  a  portion  of  periosteum  with  the  cyst. 


CYSTS.  301 

Hydatid  cysts  are  especially  common  in  Iceland,  and  are 
frequent  in  Australia  and  South  America,  but  are  very  rare 
in  the  United  States.  They  are  due  to  echinococci. 
The  adult  echinococcus  is  the  tapeworm  of  the  dog  (taenia 
echinococcus),  and  its  ova  or  larvjE  gain  access  to  man's 
body  by  accompanying  the  food  he  eats  and  passing  into 
the  alimentary  canal,  from  which  situation  they  are  trans- 
ported to  various  organs  by  the  blood.  Osier  says  the 
embryo  (which  has  six  booklets)  burrows  through  the  wall 
of  the  bowel  and  enters  the  peritoneal  cavity  or  muscles ;  it 
may  enter  the  portal  vessels  and  reach  the  liver,  or  may 
enter  the  systemic  circulation  and  pass  to  distant  parts.  The 
danger  depends  on  two  factors :  "  the  situation  and  the 
liability  of  the  cyst  to  suppurate  "  (Sidney  Coupland).  The 
organs  most  usually  attacked  are  the  liver  and  lung.  In  60 
per  cent,  of  cases  the  liver  suffers,  and  in  12  per  cent,  the 
lung  (Thomas).  Cysts  sometimes  arise  in  the  intestine, 
genito-urinary  passages,  brain,  or  spinal  canal.  When  the 
embryo  lodges  the  booklets  disappear  and  the  embryo 
is  converted  into  a  cyst.  This  cyst  is  composed  of  two 
layers,  an  outer  capsule  (cuticular  membrane)  and  an  inner 
layer  (endocyst).  The  cyst  contains  clear  fluid.  As  the 
cyst  grows,  daughter-cysts  bud  out  from  the  wall  of  the 
mother-cysts,  the  structure  of  the  daughter-cysts  being 
identical  with  that  of  the  mother-cyst.  From  the  lining 
membrane  of  all  the  cysts,  after  a  time,  growths  arise  known 
as  scolices,  which  represent  the  head  of  the  echinococcus 
and  exhibit  four  sucking  disks  and  a  row  of  booklets  (Osier). 

The  fluid  is  not  albuminous,  is  occasionally  saccharine,  is 
thin  and  clear,  and  may  contain  scolices  or  booklets. 

A  hydatid  cyst  may  calcify,  may  rupture,  or  may  suppurate. 
These  cysts  are  very  firm,  but  usually  fluctuate.  Palpation 
with  one  hand  while  percussion  is  practised  with  the  other 
gives  a  persistent  tremor  (hydatid  fremitus).  If  the  cyst  can 
be  safely  reached,  some  fluid  should  be  drawn  and  examined 
for  diagnostic  purposes.  When  a  cyst  suppurates  positive 
constitutional  and  local  symptoms  arise.  Hydatid  cysts  of 
the  brain  and  cord  tend  to  produce  death  in  the  same  manner 
as  do  tumors.  In  the  liver  a  cyst  may  rupture  into  the  pleural 
sac,  into  the  belly  cavity,  into  the  stomach  or  bowel,  pro- 
ducing shock,  hemorrhage,  and  probably  death.  In  rare 
cases  hydatid  cysts  rupture  into  the  pericardium  or  into  a 
great  abdominal  blood-vessel,  or  externally.  Rupture  into 
the  bile-passages  is  usually  followed  by  suppuration  of  the 
cyst.     Suppuration  of  a  cyst  may  follow  uncleanly  tapping. 


302    DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

TrcatDient. — An  unruptured  hydatid  cyst  of  a  superficial 
structure  should  be  incised  and  the  sac-wall  should  be  dis- 
sected out.  Hy^datid.s.jaf-  the  brain  have  been  siiccessfully 
removed  in  Australia.  A  cyst  of  the  kidney  is  removed 
through  a  lumbar  incision.  Omental  cysts  should  be  radically 
removed  if  possible ;  if  this  is  not  possible,  open  the  abdo- 
men, surround  with  gauze,  evacuate  through  a  trocar,  stitch 
the  cyst  to  the  wound,  incise,  irrigate,  and  drain  with  gauze. 
Bond  advocated  evacuating  the  cyst,  closing  it  with  sutures, 
and  dropping  it  back  in  the  abdomen.  Gardner  says  tapping 
is  dangerous,  as  it  may  cause  rupture  of  the  cyst.  In  a  hydatid 
of  the  liver  the  abdomen  should  be  opened,  the  cyst  should 
be  surrounded  with  gauze  pads,  and  tapped  with  a  trocar  and 
cannula.  When  the  cyst  is  emptied  of  fluid  it  is  grasped 
with  forceps  and  pulled  to  the  incision  in  the  abdominal 
wall,  it  is  sutured  to  this  incision,  the  trocar-opening  is 
enlarged,  and  the  endocyst  is  removed  by  irrigation.^  This 
operation  is  called  marsupialization.  If  the  cyst  is  on  the  sum- 
mit of  the  liver,  it  may  be  reached  by  a  transpleural  hepatot- 
omy.  If  aspiration  is  performed  to  settle  a  diagnosis,  oper- 
ate at  once  after  doing  it,  because  of  fear  that  the  cyst  may 
leak  and  disseminate  the  disease  throughout  the  peritoneal 
cavity.  If  hydatid  fluid  is  disseminated  throughout  the  peri- 
toneal cavity,  it  may  or  may  not  lead  to  the  development  of 
new  cysts,  but  it  is  almost  certain  to  cause  a  febrile  condition 
known  as  hydatid  toxemia. 

XVHL    DISEASES   AND    INJURIES   OF  THE    HEART 
AND  VESSELS. 

Heart  and  Pericardium. — In  an  acute  pulmonary  con- 
gestion the  venous  side  of  the  heart  is  over-distended_  with 
blood,  and  the  surgeon  in  desperate  cases  may  tap  the  right 
auricle  (see  Paracentesis^  Auriculi).  Pericardial  effusion,  if 
severe,  calls  for  tapping  or  aspiration,  and  purulent  peri- 
carditis demands  incision  and  drainage. 

Wounds  and  Injuries. — The  heart  may  rupture  and 
cause  instant  death,  severe  wounds  usually  though  not  always 
produce  death,  but  slight  wounds  may  not  prove  fatal.  It  is 
a  popular  impression  that  the  expression  "  shot  in  the  heart  " 
or  "  stabbed  to  the  heart"  is  another  way  of  saying  that  in- 
stant death  has  occurred.  This  view  Avas  overthrown  b}^  ex- 
periments performed  upon  animals  by  Del  Vechio  and  Phil- 
oppoo  and  by  Block.    These  observers  showed  that  pericardial 

1  John  O'Conor,  of  Buenos  Ayres,  in  Annals  of  Surgery,  May,  1897. 


WOUNDS  AND    INJURIES.  3O3 

and  cardiac  wounds  are  not  of  necessity  instantly  fatal,  and 
that  in  some  cases  they  can  be  successfully  sutured.  Several 
times  during  post-mortem  examinations  on  human  beings 
healed  scars  have  been  found  upon  the  heart.  The  heart 
has  been  punctured  a  number  of  times  accidentally  or  inten- 
tionally, and  death  has  not  ensued.  John  B.  Roberts  ^  of 
Philadelphia  suggested  in  1881  that  it  would  be  proper  to  try 
to  suture  wounds  of  the  heart.  A  wound  of  the  heart  causes 
hemorrhage,  usually  copious  ;  but  owing  to  the  interlocking 
of  muscular  fibers  the  hemorrhage  is  often  slight.  Bleeding 
may  take  placejjito  the  pericardial  sac  in  some  cases  where 
the  pericardium  has  been  injured  and  the  heart  has  escaped. 
Such  an  Injury  is  occasionally  inflicted  by  the  sharp  end  of 
a  fractured  rib.  The  wound  is  rarely  at  or  near  the  apex  of 
the  sac.  In  some  cases  the  pleural  cavity  is  opened  and 
severe  hemothorax  occurs.  The  lung  may  or  may  not  be 
injured.  A  wound  of  the  pericardium  or  heart  causes  pro- 
found shock,  irregular  or  very  weak  pulse,  sighing  respira- 
tion, dyspnea,  and,  it  may  be,  the  signs  of  hemopericardium 
or  hemothorax:.  There  may  or  may  not  be  serious  external 
bleeding.  Fatal  concealed  hemorrhage  may  occur.  Pain 
is  constant,  and  attacks  of  syncope  are  the  rule.  Death  is 
apt  to  occur  suddenly  from  shock,  hemorrhage,  and  inability 
of  the  heart  to  contract  because  of  the  severed  fibers,, or  in- 
ability of  the  heart  tt)  dilate  because  of  the  pressure  of  blood 
in  the  pericardial  sac.  If  a  wound  of  the  pericardium  or 
heart  does  not  cause  death  in  the  first  day  or  two,  inflamma- 
tion follows  (traumatic  pericarditis  or  carditis). 

Treatment. — Wounds  of  the  pericardium  and  heart  should 
be  sutured,  and  every  effort  should  be  made  to  antagonize 
shock  during  the  operation.  The  patient  should  be-^Yrapped 
in  hot  blankets  and  surrounded  with  hot  bottles  or  hot  water- 
bags,  or  should  be  placed  upon  a  table  composed  of  pipes  in 
which  hot  water  circulates.  The  foot  of  the  bed  should  be 
raised.  Hot  saline  fluid  should  be'^infused  into  a  vein.  The 
extremities,  except  the  one  selected  to  infuse  salt  solution  in, 
should  be  bandaged  (auto-transfusion),  an  enema  of  hot  cof- 
fee and  whiskey  should  be  given,_and  strychnin  or  atropin 
should  be  given  Hypodermatically.  It  is  rarely  proper  to  give 
a4.\anesthetjc.  The  heart  is  exposed  by  resecting  several  ribs, 
and  uslially  the  pleural  sac  is  opened.  Parrozzanijnakes  a 
trap-door  in  the  cliest^the  hinges  of  tlie  door  being  the  rib- 
cartilages.  The  heart  is  exposed,  clotsare  removedfrom  the 
pericardial  sac,  and  the  sac  is  irrigated  with  hot  saline  fluid. 

^  The  author,  in  Progressive  Medicine,  vol.  i.,  1899. 


304    DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

A  wound  in  the  heart  is  sutured  with  silk,  which  is  passed 
by  means  of  a  round,,  curved  needle,  and  if  a  cavity  of  the 
heart  is  open,  the  suture  includes  the  whole  thickness  of  the 
heart-wall  except  the  endocardium.  The  pericardium,  is 
sutured  with  silk,  or,  as  was  done  in  one  successful  case,  the  sac 
is  packed  with  iodoform ^auze(Rehn's  case).  It  is  not  abso- 
lutety~necessary  to  drain  the  pericardial  sac.  Clots  are  re- 
moved from  the  pleural  sac  by  irrigation  Avith  hot  saline  .so- 
lution, pulmonary  bleeding  is  arrested  by  the  suture  or  by 
packing,  and  a  wound  in  the  lung,  especially  if  it  com- 
municates with  the  air-passages,  should  be  sutured  if  the 
patient's  condition  justifies  prolonging  the  operation.^ 

After  such  an  operation  the  patient  is  in  great  danger,  and 
every  effort  should  be  made  to  save  him  from  shock.  In  per- 
forming operations  upon  the  heart  the  pleura  may  be  opened 
by  design  or  by  accident.  When  the  pleura  is  opened  there 
is  always  danger  of  pneumothorax,  pulmonary  collapse,  and 
overwhelming  shock.  It  is  always  well  in  such  cases  to  have 
at  hand  the  Fell-O'Dwyer  apparatus,  which  will  prevent  or 
amend  pulmonary  collapse. 

Dalton  has  sutured  the  pericardium.  Rehn,  sutured  a 
wound  of  the  heart  and  packed  the  pericardium  with  gauze, 
and  the  patient  recovered.  Parrozzani  successfully  sutured 
a  wound  of  the  ventricle.  Williams  reports  recovery  after 
a  stab-wound  of  the  heart,  the  pericardium  having  been 
sutured.  Fareni  sutured  a  stab-wound  of  the  left  ventricle, 
and  the  patient  lived  several  days.  Cappelan  sutured  a 
wound  of  the  heart,  and  the  patient  lived  two  and  one-half 
days.  Traumatic  carditis  or  pericarditis  is  treated  in  the  same 
way  as  idiopathic  cases.  Pus  in  the  pericardial  sac  should 
be  evacuated  by  resection  of  the  fourth  left  costal  cartilage 
and  incision  of  the  pericardium  (von  Eiselberg's  case). 

Phlebitis,  or  Inflammation  of  a  Vein. — Phlebitis  may 
h& plastic,  or  it  may  be  vifectivc.  Plastic  phlebitis,  while  occa- 
sionally due  to  gout,  to  a  febrile  malady,  or  to  some  other 
constitutional  condition,  usually  takes  its  origin  from  a  wound 
or  other  injury,  from  the  extension  to  the  vein,  of  a  peri- 
vascular inflammation,  or  in  the  portal  region  from  an  em- 
bolus. Varicose  veins  are  particularly  liable  to  phlebitis. 
When  phlebitis  begins  a  thrombus  forms  because  of  the 
destruction  of  the  endothelial  coat  of  the  vessel,  and  this 
clot  may  give  rise  to  emboli,  may  be  absorbed,  or  may  be 
organized.  Infective  phlebitis  is  a  suppurative  inflammation 
of  a  vein,  arising  by  infection  from  suppurating  perivascular 

^  The  author,  on  "Suture  of  the  Heart,"  in  Progressive  Medicine,  vol.  i,,  1899. 


VARICOSE    VEIXS.  305 

tissues  (infective  thrombophlebitis).  It  is  not  unusually  met 
with  in  cellulitis  or  phlegmonous  erysipelas,  may  arise  in  the 
lateral  sinus  as  a  result  of  mastoid  suppuration,  or  in  the  liver 
fro_m  appendicitis  or  phlebitis  of  the  rectal  veins.  A  throm- 
bus forms,  the  vein-wall  suppurates,  is  softened  and  in  part 
destroyed,  and  the  infected  clot  softens  and  gives  rise  to 
emboli.  No  bleeding  occurs  when  the  vein  ruptures,  as  a 
barrier  of  clot  keeps  back  the  blood-stream.  The  clot  of 
suppurative  phlebitis  cannot  be  absorbed  and  cannot  organ- 
ize. Septic  phlebitis  causes  pyemia,  and  the  infected  clots 
of  pyemia  cause  phlebitis  at  the  points  of  lodgement. 

Symptoms. — The  symptoms  of  plastic  phlebitis  are  pain, 
tenderness  in  and  around  a  vein,  discoloration  over  it,  and 
edema  below  the  seat  of  the  disease.  Suppurative  phlebitis, 
besides  these  conditions,  causes  the  constitutional  symptoms 
of  pyemia  (p.  178). 

Treatment. — The  treatment  of  plastic  phlebitis  comprises 
rest  in  bed^  bandaging^  and  elevation  of  the  part,  and  the 
local  use  of  ichthyol.  Hot  fomentations  are  used  later  in 
the  case.  The  danger  is  embolism ;  hence  massage  and  both 
active  and^a^sive^  rnovement  are  dangerous.  When  a  vein 
is  involved  in  a  suppurative  process  and  septic  thrombo- 
phlebitis exists,  ligate  the  vein,  if  possible,  above  and  below 
the  clot,  open  the  vessel,  and  wash  out  the  infected  clot. 
This  plan  of  treatment  is  always  to  be  applied  in  infective 
thrombophlebitis  of  the  lateral  sinus  and  of  the  internal 
saphenous  vein.  The  constitutional  treatment  is  that  of 
pyemia. 

Varicose  Veins;  Phlebectasis,  Phlebectasia,  or 
Varix. — Definition  and  Causes. — -Varicose  veins  are  un- 
natural, irregular,  and_  permanently  dilated  veins  which  are 
elongated  and  pursue  a  tortuous  course.  This  condition  is 
very  common,  and  20  per  cent,  of  adults  exhibit  it  in  some 
degree  in  one  region  or  another.  The  causes  of  varicose 
veins  are  obstruction  to  venous  return  and  weakness  of 
cardiac  action,  which  lessens  the  propulsion  of  the  blood- 
stream. 

Varicose  veins  may  occur  in  any  portion  of  the  body,  but 
are  chiefly  met  with  on  the  inner  side  of  the  lower  extremity, 
in  the  spermatic  cord,  and  in  the  rectum.  Vadx^in  the  leg 
is  niet  with  during  and  after  pregnancy  and  in  persons  who 
stand  upon  their  feet  for  long  periods.  It  is  especially  common 
in  the  long  saphenous  vein,  which,  being  subcutaneous,  has  no 
muscular  aid  in  supporting  the  blood-column  and  in  urging 
it  on.  The  deep  as  well  as  the  superficial  veins  may  become 
20 


306    DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

varicose.  Verneuil  maintained  that  varix  of  the  superficial 
veins  is  almost  always  secondary  to  varix  of  the  deep 
veins,  a  radical  view  which  seems  improbable.  It  is  certain, 
however,  that  after  contusions  of  the  leg  it  is  not  unusual 
for  the  deep  veins  To  "b'ecCrme  filled  with" "clot  and  for  the 
superficial  veins  to  dilate  notably.  By  the  term  "  caput 
medusae  "is  meant  dilated  veins  radiating  from  the  umbilicus. 
The  veins  of  the  esophagus  may  become  varicose,  and  this 
malady  is  commonly  unrecognized  clinically.  Varicose 
veins  are  in  rare  instances  congenital ;  but  they  are.  xuQst 
often  seen  in  the  aged,  and  usually  begin  between  the. ages 
of  twenty  and  forty.  They  are  more  common  in  women 
than  in  men  because  of  the  influence  of  pregnancy. 

Varix  of  the  spermatic  cord  is  known  as  "  varicocele." 
It  is  apt  to  appear  about  the  time  of  puberty,  and  most  adult 
men  have  at  least  a  slight  varicocele.  Varix  is  more  likely 
to  appear  in  the  left  spermatic  vein  than  in  the  vein  of  the 
right  side,  because  the  left  spermatic  vein  has  no  valves 
{Brinton). 

Varix  of  the  veins  of  the  rectum  is  known  as  "hemor- 
rhoids" or  "piles."  Piles  are  caused  by  obstruction  to  the 
upward  flow  in  the  hemorrhoidal  veins,  either  by  obstructive 
liver  disease,  enlargement  of  the  uterus  or  prostate,  or  the 
presence  in  the  rectum  of  fecal  masses  in  a  person  habitually 
constipated. 

A  vein  under  pressure  usually  dilates  more  at  one  spot 
than  at  another,  the  distention  being  greatest  back  of  a  valve 
or  near  the  mouth  of  a  tributary.  The  valves  become  in- 
competent and  the  dilatation  becomes  still  greater.  Callen- 
der  has  pointed  out  that  varix  is  apt  to  begin  where  the 
deep  vessels  join  the  superficial  veins.  At  this  point  Treves 
says  three  forces  meet,  the  blood-column  above,  the  valve 
below,  and  the  force  of  the  blood-current.  At  this  point 
the  vein-wall  dilates,  and  from  this  dilatation  the  blood-current 
is  deflected  and  causes  another  dilatation  higher  up  and  on 
the  opposite  side  of  the  vessel.  The  blood  is  again  deflected 
and  causes  another  dilatation,  and  so  on  (Agnew).  The 
vein-wall  may  become  fibrous,  but  usually  it  is  thin  and 
sometimes  it  ruptures.  The  veins  not  only  dilate,  but  they 
also  become  longer,  and  hence  do  not  remain  straight,  but 
twist  and  assume  a  characteristic  form.  Varicose  veins  are 
apt  to  cause  edema,  and  the  watery  elements  in  the  tissues 
cause  eczema  of  the  skin.  When  eczema  is  once  inaugurated 
excoriation  is  to  be  expected.  Infection  of  an  excoriated 
area  produces  inflammation,  suppuration,  and  an  ulcer. 


VARICOSE    VEINS.  307 

Delbet  ^  points  out  that  varicose  veins  of  the  leg,  which 
beo-an  in  the  thigh,  result  from  valvular  incompetence,  and 
ulcers  arise  from  variations  of  pressure  due  to  valvular  in- 
competence. This  incompetence  of  the  valves  does  harm 
by  allowing  the  intravenous  pressure  to  equal  the  pressure 
in  the  arterioles,  a  condition  which  arrests  capillary  circula- 
tion and  causes  congestion,  and  greatly  lowers  tissue-resist- 
ance. Incompetent  valves  also  favor  ulceration  by  developing 
a_  vicious  venous  circle  first  described  by  Trendelenburg. 
Blood  passing  through  this  circle  loses  nutritive  elements. 
Trendelenburg  has  described  the  vicious  circle  as  follows: 
Blood  in  the  saphenous  vein  flows  toward  the  periphery 
instead  of  toward  the  center,  it  passes  into  the  veins  which 
connect  the  superficial  veins  with  the  deep  veins  and  then 
enters  the  tibial  and  peroneal  veins.  It  passes  from  the 
tibial  and  peroneal  into  the  popliteal  and  femoral  veins,  and 
some  of  it  leaves  the  femoral  vein  and  again  enters  the 
saphenous. 

The  skin  over  varicose  veins  in  the  leg  is  often  discolored 
by  pigmentation  due  to  the  red  blood-cells  having  escaped 
from  the  vessel  and  broken  up.  The  tissues  around  a  vari- 
cose vein  become  atrophied  from  pressure,  and  it  is  not 
unusual  to  meet  with  a  very  large  vein  whose  thin  walls 
are  in  close  contact  with  skin.  In  this  condition,  rupture 
and  hemorrhage  are  probable.  When  the  vein-wall  forms  a 
pouch-like  dilatation  the  condition  is  spoken  of  as  a  cyst. 
Varicose  veins  are  apt  to  inflame,  and  thrombosis  frequently 
occurs.  When  a  thrombus  forms,  especially  if  the  patient 
walks  aboutj  emboli  may  be  broken  off  and  carried  into  the 
circulation,  but  embolic  formation  is  not  so  common  in 
thrombosis  in  a  varicose  vein  as  in  thrombosis  in  an  undis- 
tended  and  unelongated  vessel. 

Treatment. — The  treatment  of  varix  may  be  palliative  or 
curative,  but  whichever  plan  is  followed,  the  surgeon  should 
endeavor  first  of  all  to  remove  the  exciting  cause.  An 
essential  part  of  palliative  treatment  is  to  attend  to  the  gen- 
eral health,  to  keep  up  -the  force  and  activity  of  the  circu- 
lation, and  to  prevent  constipation.  The  patient  should 
exercise  in  the  open  air  and  should  lie  down  for  a  time,  if  pos- 
sible, every  afternoon.  Locally,  in  varix  of  the  leg,  use  a 
flannel  roller  or  a  Martin  rubber  bandage  to  support  the  veins 
and  drive  the  blood  into  the  deeper  vessels  which  have  mus- 
cular support.  The  use  of  a  rubber  pad  filled  with  glycerin 
and  applied  over  the  saphenous  vein  so  as  to  support  the 

1  Sevi.  7ned.,  October  13,  1897. 


308   DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

blood-column  and  act  as  a  valve,  has  been  recommended. 
Locally,  in  varicocele,  pour  cold  water  upon  the  scrotum 
twice  a  day  and  order  the  patient  to  wear  a  suspensory 
bandage.  Locally,  in  hemorrhoids,  use  injections  of  ice- 
water  and  astringent  suppositories.  A  purely  local  varix 
should  be  excised,  because  there  is  always  danger  of  injury, 
and  consequently_  of  hemorrhage  or  thrombosis.  If  the 
superficial  veins  have  dilated  because  of  thrombosis  of  the 
deep  veins  and  edema  exists,  operation  is  contraindicated, 
as  its  performance  might  lead  to  permanent  edema.  If  the 
disease  involves  the  leg  only,  operative  treatment  is  rarely 
required,  and  may  even  do  harm.  Such  cases  are  operated 
upon  if  there  are  cyst-like  dilatations  ;  if  thrombi  form  and, 
as  Bennett  points  out,  if  a  thin-walled  vein  crosses  the  tibia, 
and  is  thus  exposed  to  the  danger  of  injuiy  and  thrombosis.^ 

If  the  leg  is  involved  in  the  process,  and  the  saphena  in 
the  thigh  is  also  varicose,  operation  should  be  performed. 

If  a  thrombus  forms  in  a  varicose  vein,  tie  the  vein  above 
and  below  the  clot,  divide  the  vessel  in  two  places,  and 
remove  the  vein  and  the  clot  within  it.  Thrombus  in  a 
varicose  vein  is  not  so  apt  to  lead  to  emboli  as  thrombus  in 
a  non-varicose  vein,  but  it  may  do  so,  and  the  condition  is 
dangerous. 

The  radical  treatment  of  varix  of  the  leg  often  does  good, 
often  relieves  some  annoying  condition,  but  rarely  absolutely 
cures  (W.  H.  Bennett).  There  are  several  methods  of  oper- 
ation :  ligation  with  excision  of  part  of  the  vein,  exposure 
and  ligation  of  the  vein  below  the  saphenous  opening,  cir- 
cular incision  around  the  leg  (see  Operations  upon  Vessels). 

Nevus. — fSee  Tumors.) 

Arteritis,  or  inflammation  of  an  artery,  is  aaite  or  chronic. 

Acute  arteritis  may  result  from  injury  or  from  extension 
of  inflammation  from  the  perivascular  tissues  (aseptic  or 
productive  arteritis).  Arteries  are  very  resistant  to  the 
spread  of  inflammation,  but  we  sometimes  meet  with  sup- 
purative arteritis  in  suppurating  areas.  In  acute  suppurative 
arteritis  the  coats  ulcerate  through,  but  hemorrhage  rarely 
occurs  unless  a  considerable  portion  of  the  vessel  sloughs. 
Septic  emboli  lodging  in  the  arterial  system  produce  acute 
septic  arteritis.  This  is  seen  during  the  progress  of  ulcera- 
tive endocarditis. 

Chronic  arteritis  is  due  to  increase  of  blood-pressure 
from  hard  work,  strains,  heart-disease,  or  contracted  kidneys. 
It  is  especially  common  in  drunkards,  but  it  occurs  also  in 

^  W.  H.  Bennett,  Lancet,  October  15,  1S98. 


ARTERITIS.  309 

aged  men  who  never  drank.  Chronic  arteritis  is  most  fre- 
quent in  the  larger  arteries.  It  is  a  true  saying  of  CazaHs 
that  "A  man  is  as  old  as  his  arteries."  and  a  young  man 
dilapidated  by  syphilitic  disease  or  alcohol  may  have  diseased 
arteries,  and  hence  be  really  older  than  a  healthy  man  of 
sixty,  'in  chronic  arteritis  exudation  of  serum  and  migration 
of  leukocytes  take  place  beneath  the  intima,  and  a  like  exuda- 
tion soon'  becomes  manifest  in  the  media,  in  the  adventitia, 
and  even  in  the  sheath.  The  exudate  may  be  absorbed,  or 
connective  tissue-cells  may  proliferate  and  fibrous  tissue  form 
(arterial  sclerosis),  or  the  mass  of  new  cells  may  undergo 
fatt}'  degeneration  (atheroma).  When  fatt}-  degeneration 
occurs  the  endothelium  is  destroyed,  the  vessel-wall  is  dam- 
aged, and  the  blood  may  obtain  access  to  the  deeper  coats. 
Calcareous  change  may  follow  fatt\'  degeneration. 

An  atheromatous  artery  is  rigid  and  inelastic,  and  the 
parts  it  supplies  are  cold,  congested,  and  ill-nourished. 
Atheroma  is  a  frequent  cause  of  thrombosis,  aneur\-sm, 
senile  gangrene,  and  apoplex}^  Syphilitic  arteritis  is  char- 
acterized by  an  enormous  gro\\th  of  granulation-tissue  from 
the  inner  coats  (obliterative  endarteritis )  of  arteries  of  small 
size.  Calcification  of  an  arten.-  ma\-  be  secondary  to  fatt}' 
change,  or  may  occur  primarih-  from  deposit  of  lime  salts  in 
the  middle  coat.  Periarteritis  is  inflammation  of  the  sheath 
and  outer  coat.  An  acute  arteritis  is  always  local,  but  a 
chronic  arteritis  may  be  general. 

Treatment  of  acute  arteritis  consists  of  rest,  elevation, 
and  relaxation,  and  the  application  of  ichthyol  ointment.  Hot 
fomentations  are  applied  later.  If  abscesses  form  in  a 
septic  case,  they  must  be  opened  and  drained.  Internally, 
treat  any  diathesis  (rheumatic,  gout}-,  or  s}-philitic\  maintain 
kidnev  secretion,  quiet  the  circulation,  and  employ  a  non- 
stimulating  diet.  The  part  must  be  kept  quiet,  as  rough 
movement  would  tend  to  rupture  the  vessel. 

Treatment  of  Chronic  Arteritis,— In  treating  chronic 
arteritis,  endeavor  to  antagonize  the  dangers  to  which  the 
patient  is  obviously  liable.  Stop  alcohol  as  a  beverage, 
though  a  little  whiskey  may  be  taken  at  meals  to  aid  di- 
gestion. :\Iaintain  the  activit}^  of  the  skin  by  daih-  baths, 
and  of  the  kidneys  by  diuretic  waters.  A  daily  bowel 
movement  should  be  secured.  The  diet  is  to  be  plain  and  is 
to  contain  a  minimum  of  nitrogen.  If  s}-philis  has  existed, 
occasional  courses  of  iodid  of  potassium  are  to  be  given.  If 
the  arterial  tension  at  anytime  becomes  inordinately  high, 
administer  nitroglycerin.     One  danger  to  which  the  patient  is 


3IO   DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

liable  is  apoplexy ;  hence  excitement  and  violent  exercise 
are  to  be  avoided.  Another  danger  is  senile  gangrene ; 
hence  the  patient  should  wear  woollen  stockings,  put  a  hot 
bottle  to  his  feet  at  night,  and  be  careful  to  avoid  injuring 
his  toes  or  feet,  especially  when  cutting  his  corns.  When 
a  patient  with  atheroma  has  dyspnea  and  is  of  a  livid  color, 
or  when  the  arterial  tension  is  very  high,  a  moderate  blood- 
letting (sixteen  to  eighteen  ounces)  does  good,  and  may 
prevent  or  arrest  edema  of  the  lungs.  Still  another  danger 
is  aneurysm,  which  may  appear  suddenly  from  rupture  or 
gradually  from  progressive  distention. 

Aneurysm. — An  aneurysm  is  a  pulsating  sac  containing 
blood  and  communicating  with  the  cavity  of  an  artery. 
Some  restrict  the  term  "true  aneurysm"  to  a  condition  of 
dilatation  involving  all  the  coats  of  the  vessel.  We  shall 
consider,  with  Heath,  a  triie  aneurysm  to  be  one  in  which 
the  blood  is  included  in  one  or  more  of  the  arterial  coats, 
and  a  false  aneuiysm  to  be  a  condition  in  which  the  vessel 
has  ruptured  or  has  atrophied  and  the  aneurysmal  wall  is 
formed  by  a  condensation  of  the  perivascular  tissues. 

Forms  of  Aneurysm. — The  following  forms  of  aneurysm 
are  recognized : 

1.  Tnie  aneurysm — one  whose  sac  is  formed  of  one  or 
more  arterial  coats. 

2.  False  aneurysm — one  whose  sac  is  formed  of  condensed 
perivascular  tissues  and  contains  no  arterial  coat. 

3.  Traumatic  aneurysm — a  false  aneurysm  due  to  trau- 
matic rupture  some  time  before,  the  blood  being  in  a  sac  of 
tissue  and  any  wound  being  healed. 

4.  Fusiform  aneurysm — a  variety  of  true  aneurysm,  the 
sac  being  spindle-shaped. 

5.  Consecutive  aneurysm — a  sacculated  aneurysm  diffused 
by  rupture,  or  a  false  aneurysm  due  to  gradual  destruction 
or  atrophy  of  a  true  aneurysmal  sac  or  to  vascular  rupture. 

6.  Sacculated  aneurysm — a  common  form  of  aneurysm,  in 
which  the  dilatation  is  like  a  pouch,  arising  from  a  part  of 
the  arterial  circumference  and  joining  the  lumen  of  the  vessel 
by  an  aperture. 

7.  Dissecting  aneurysm  (Shekelton's  aneurysm) — a  pouch- 
like dilatation  of  an  artery  due  to  the  blood  which  has  gained 
access  to  the  middle  coat  through  an  atheromatous  ulcer 
or  a  minute  rupture  of  the  inner  coat.  It  used  to  be  taught 
that  the  blood  flows  between  the  media  and  adventitia  ;  we 
now  know  that  it  flows  between  the  layers  of  the  middle 
coat.     The  outer  wall  of  the  aneurysm  consists  of  adventitia 


ANEURYSM.  3II 

and  a  portion  of  the  middle  coat.  It  may  or  may  not  join 
the  lumen  of  the  artery  at  another  point  by  a  fresh  aperture 
in  the  intima.  Dissecting  aneurysm  is  practically  only  met 
with  in  the  aorta.  It  is  most  common  in  the  thoracic  aorta. 
About  eighty  cases  have  been  reported.^ 

8.  Artcriozienous  aneurysm,  which  is  divided  into  aneu- 
rysmal varix,  or  Pott's  aneurj^sm,  where  there  is  direct  com- 
munication between  a  vein  and  an  artery;  and  varicose  aneu- 
r}-sm,  where  there  is  communication  between  an  arter\'  and 
a  vein  by  means  of  an  interposed  sac. 

9.  Acute  anciirysni — a  cavit>'-  in  the  walls  of  the  heart, 
which  cavity  communicates  with  the  interior  of  this  organ, 
and  which  is  due  to  suppuration  in  the  course  of  acute  endo- 
carditis or  myocarditis. 

10.  Aneurysju  by  anastomosis  (see  Angiomata). 

11.  Anetirysm  of  bone — an  inaccurate  clinical  term  used  to 
designate  a  pulsatile  tumor  of  bone. 

12.  Circumscribed  aneurysm — when  the  blood  is  circum- 
scribed by  distinct  walls. 

13.  Cirsoid  aneurysm — a  mass  of  dilated  and  elongated 
arteries  shaped  like  varicose  veins  and  pulsating  with  each 
heart-beat. 

14.  Cylindrical  aneurysm — a  dilatation  which  maintains 
the  same  dimensions  for  a  considerable  space. 

15.  Embolic  or  capillary  aneurysm — dilatation  of  terminal 
arteries  due  to  emboli. 

16.  Spontaneous  aneurysm — non-traumatic  in  origin. 

17.  Miliary  aneurysm — a  minute  dilatation  of  an  arteriole. 

18.  Secondary  aneurysm — one  which,  after  apparent  cure, 
again  pulsates,  the  blood  entering  by  means  of  the  anasto- 
motic circulation. 

19.  J ''er  mi  nous  aneurysm — one  containing  a  parasite.  This 
form  of  aneur}'sm  is  met  with  in  the  mesenteric  arten.-  of  the 
horse. 

The  sac  of  a  sacculated  aneurysm  is  at  first  composed  of 
at  least  two  of  the  arterial  coats,  reinforced  by  the  sheath 
and  perivascular  tissues.  After  a  time  the  blood-pressure 
distends  the  sac,  and  the  inner  and  middle  coats  either 
stretch  with  interstitial  growth  or — what  is  more  common — 
are  worn  away  and  lost.  When  all  the  coats  are  lost,  and 
the  blood  is  sustained  only  by  the  sheath  and  surrounding 
tissue,  a  true  aneur}*sm  becomes  a  false,  diffuse,  or  consecutive 
aneurysm,  the  limiting  tissues  and  sheath  being  condensed, 
thickened,  and  glued  together.     This  limiting  process  is  de- 

^  Coleman,  in  Dublin  Jour.  Med.  Sciences,  August,  1898. 


312    DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

ficient  in  the  brain  ;  hence  cerebral  aneurysms  break  soon 
after  their  formation.  When  all  the  arterial  coats  are  lost, 
the  blood-pressure,  acting  on  the  tissues,  finds  some  spots 
less  resistant  than  others,  the  blood  follows  the  lines  of  least 
resistance,  the  aneurysm  grows  with  great  rapidity,  and  soon 
ruptures  externally  or  into  a  cavity. 

An  aneurysm  may  rupture  into  a  cavity  (pleural,  pericar- 
dial, or  peritoneal),  into  the  perivascular  tissues,  or  through 
the  skin.  Rupture  into  the  tissues  may  produce  pressure- 
gangrene.  When  rupture  occurs  through  the  skin  the 
hemorrhage  is  not  often  instantly  fatal,  but  during  several 
days  constantly  recurs  in  larger  and  larger  amounts.  The 
pressure  of  an  aneurysmal  sac  causes  atrophy  of  tissues, 
hard  and  soft,  bones  and  cartilages  being  as  easily  destroyed 
as  muscles  and  fat.  Sometimes  the  perivascular  tissues  in- 
flame and  suppurate,  and  the  sac  is  opened  rapidly  by 
sloughing.  An  aneurysm  usually  progresses  toward  rupt- 
ure, the  slowest  in  this  progression  being  the  fusiform  dila- 
tations, which  may  exist  for  many  years,  but  which  finally 
is  converted  into  the  sacculated  variety. 

In  some  rare  instances  there  takes  place  spontaneous  cure, 
which  may  result  from  laminated  fibrin  being  deposited  upon 
the  walls  of  the  sac  as  the  blood  circulates  through  it.  This 
laminated  fibrin  is  known  as  an  "  active  clot,"  and  eventu- 
ally fills  the  sac.  The  weaker  and  slower  the  blood-stream, 
the  greater  is  the  tendency  to  the  formation  of  an  active 
clot ;  hence  any  agent  impeding,  but  not  abolishing,  the  cir- 
culation aids  in  the  deposition.  This  weakening  and  slowing 
of  circulation  may  be  brought  about  by  great  activity  of  the 
collateral  circulation  deviating  most  of  the  blood  away  from 
the  area  of  disease.  Sometimes  a  clot  breaks  off  from  the 
sac-wall  and  plugs  the  artery  beyond  the  aneur}^sm,  and  the 
anastomotic  vessels,  enlarging,  divert  the  blood-stream.  A 
large  aneurysm,  falling  over  by  its  own  weight  upon  the  vessel 
above  the  mouth  of  the  sac,  may,  in  very  unusual  cases, 
diminish  the  blood-stream.  The  development  of  another 
aneurysm  upon  the  same  vessel  nearer  to  the  heart  weakens 
the  circulation  in  and  may  cure  the  older  one.  Inflammation 
occasionally  forms  a  clot.  The  tissues  about  an  aneurysm 
tend  to  contract  when  arterial  force  is  lessened  ;  hence  tissue- 
pressure  may  more  than  counteract  blood-pressure  when  the 
circulation  is  feeble.  Clotting  of  the  blood  contained  within 
a  sac,  circulation  through  the  aneurysm  having  ceased,  causes 
a  passive  clot.  A  passive  clot,  which  occasionally  cures,  may 
arise  from  a  twisting  of  the  neck  of  the  sac,  preventing  the 


AXECJ^VSM.  313 

passage  of  blood  ;  from  the  lodgement  of  a  clot  in  the  mouth 
of  the  sac ;  and  from  inflammation.  Spontaneous  cure  is, 
unfortunatel}-,  very  rare. 

Causes  of  Aneurysm. — Gradual  distention  of  arterial 
coats  which  are  in  a  condition  of  arterial  sclerosis,  or  of 
coats  whose  resisting  power  is  lowered  because  of  atheroma, 
may  cause  aneur\"sm.  Hence  the  causes  of  sclerosis  and 
atheroma  are  also  causes  of  aneurysm.  The  principal  cause 
of  aneur\-sm  is  increased  blood-pressure.  This  increase 
may  be  brought  about  by  severe  labor;  by  sudden  strains, 
as  in  lifting;  by  violent  eftbrts,  as  in  rowing  in  a  boat-race; 
by  chronic  interstitial  nephritis;  by  hypertrophy  of  the 
heart;  by  alcoholic  inebriet}";  and  by  syphilis.  Arterial  dis- 
ease is  commonest  in  the  larger  vessels  and  in  the  aged,  but 
it  may  occur  in  youth.  When  an  aneurysm  follows  a  strain, 
it  may  be  due  to  laceration  of  the  media  and  loss  of  resist- 
ance at  a  narrow  point  The  intima  may  lacerate,  permit- 
ting the  blood  to  come  in  contact  with  the  media  or  causing 
blood  to  diffuse  between  the  coats  (dissecting  aneurysm). 
When  an  embolus  lodges  in  an  arter\^  the  vessel  may  become 
aneur}-smal  on  the  proximal  side  of  the  clot.  The  embolus, 
if  infective,  causes  softening,  and  if  calcareous  causes  lacera- 
tion (Osier).  Colonies  of  micrococci  may  cause  aneurysm.^ 
The  parasite  strongvhes  armatiis  causes  aneurysm  of  the 
mesenteric  arteries  in  horses.  Suppuration  around  a  vessel 
weakens  its  coats  and  tends  to  aneurysm  by  inducing  acute 
arteritis  and  softening.  Sometimes  an  individual  develops 
multiple  aneurysms  the  origins  of  which  are  absolutely  un- 
known. 

The  constituent  parts  of  an  anenrysm  are  (i)  the  wall  of 
the  sac ;  (2)  the  cai-itv^;  (3)  the  mouth;  and  (4)  the  contents. 

Symptoms  of  Aneurysm. — An  oval  or  globular,  soft, 
elastic,  and  pulsatile  protrusion,  develops  in  the  line  of  an 
arterv".  It  is  usually  quite  evident  to  the  touch  that  the 
sac  contains  fluid,  but  sometimes  in  old  aneurysms  the  sac 
feels  firm  or  even  hard,  because  of  the  deposit  of  fibrin  upon 
its  inner  surface.  In  a  partially  consolidated  aneuiysm  pulsa- 
tion may  be  slight  or  even  inappreciable.  The  protrusion 
instantly  ceases  to  pulsate  and  almost  disappears  on  making 
firm  pressure  on  the  arten,'  above.  On  relaxing  the  press- 
ure the  pulsatile  enlargement  at  once  reappears.  Direct 
pressure  upon  the  tumor  may  cause  it  to  almost  disappear. 
Pressure  upon  the  arter}^  below  causes  the  tumor  to  enlarge. 
The  pulsation  is  expansile — that  is,  it  expands  in  all  direc- 

^  See  Osier  on  J/ali^ant  Endocarditis. 


314   DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 


tions — and  if  an  index-finger  be  laid  on  each  side  of  the 
tumor  so  that  the  points  nearly  touch,  each  pulsation  not 
only  lifts  the  fingers,  but  it  also  separates  them.  On  placing 
a  stethoscope  over  the  aneurysm  or  over  the  vessel  below 
the  aneurysm  there  is  imparted  to  the  ear  a  distinct  bruit 
which  travels  in  the  direction  of  the  blood-stream,  is  systolic 
in  time,  and  is  usually  blowing  in  character.  In  some  cases 
bruit  is  absent  (when  a  sacculated  aneurysm  has  a  very 
small  mouth,  when  the  circulation  is  tranquil,  or  when  the 
sac  is  full  of  blood  and  clot).  When  bruit  is  absent  it  may 
sometimes  be  developed  by  muscular  exercise  or  raising  the 
affected  limb  (Holloway).  In  rare  cases  there  may  be  a 
double  bruit.  Occasionally  in  fusiform  aortic  aneurysm 
linked  with  aortic  regurgitation  a  diastolic  bruit  exists.  A 
bruit  is  arrested  by  pressing  upon  the  artery  between  the 
aneurysm  and  the  heart.^  The  skin  over  an  aneurysm  may 
be  normal  or  discolored,  and  may  slough  or  ulcerate.  Aneu- 
rysm of  an  extremity  is  apt  to  produce  edema  and  varicose 
veins,  because  of  pressure  upon  large  veins  and  loss  of  vis 
a  tergo  in  circulation.  The  muscles  feel  tired,  and  some- 
times there  is  pain.  In  internal  aneurysms  pressure-symp- 
toms are  marked.  Thoracic  aneurysm  causes  intercostal  pain ; 
iliac  aneurysm  causes  pain  in  the  thigh.     Aneurysm  of  the 


Fig.  68. — Radial  pulse-tracings  in  aneurysm  of  right  brachial  arterj' :  i,  left  radial  pulse; 
2,  right  radial  pulse  (after  Mahomed). 

thoracic  aorta  pressing  upon  the  pneumogastric  nerve  causes 
spasmodic  dyspnea,  and  upon  the  recurrent  laryngeal,  causes 
loss  of  voice  and  paralysis  of  all  the  muscles  of  the  lar- 
ynx except  the  cricothyroid.  The  pulse  below  an  aneu- 
rysm is  weaker  than  the  pulse  of  the  corresponding  part  of 
the  opposite  limb.  This  is  well  shown  by  the  .sphygmo- 
graph,  the  tracings  being  rounded  without  a  sudden  rise  or 
an  abrupt  fall  (Fig.  68).  The  evidences  of  rupture  of  an 
aneurysm  of  an  extremity  into  the  tissues  are  loss  of  distinct- 
ness of  outline  and  increase  in  area  of  the  tumor,  weakening 
or  disappearance  of  both  bruit  and    pulsation,  absence  of 

^  Holloway  on  "  Aneurysm,"  in  Park's  Surgery  by  Americati  Authors. 


ANEURYSM.  315 

pulse  below  the  aneurysm,  severe  pain,  edema  and  coldness 
of  the  surface,  shock,  and  possibly  syncope.  External 
hemorrhage  may  arise ;  the  tissues  may  become  extensively 
infiltrated  with  blood;  sloughing  or  gangrene  may  ensue. 
Death  is  frequent,  and  only  in  very  rare  cases  does  spon- 
taneous cure  take  place.  Rupture  of  a  large  aneurysm  into 
a  cavity  causes  intense  pallor,  advancing  weakness,  syncope, 
and  death. 

Diagnosis. — A  cyst  or  abscess  over  a  vessel  may  show 
transmitted  pulsation  which  is  not  expansile,  and  the  tumor 
does  not  disappear  on  pressure  above  it.  The  pulsation 
ceases  when  the  growth  is  lifted  off  the  vessel,  or  when  the 
position  is  changed  so  as  to  permit  it  to  fall  away  from  the 
vessel.  There  is  no  true  bruit,  and  the  history  is  widely 
different.  A  growth  under  a  vessel  may  lift  the  vessel  and 
simulate  an  aneurysm,  but  the  pulsation  is  not  noted  in  the 
entire  growth,  the  growth  does  not  disappear  on  proximal 
pressure,  and  there  is  only  a  false,  and  never  a  true,  bruit. 
The  larger  the  growth  the  less  is  the  pulsation,  because  of 
pressure  upon  the  vessel.  A  sarcoma,  especially  a  soft  sar- 
coma attached  to  the  bone,  and  also  a  nevoid  mass,  pulsate 
and  often  have  a  bruit;  the  tumor  never  disappears  from 
proximal  pressure,  though  it  may  slowly  diminish  in  size,  to 
gradually  enlarge  again  when  pressure  is  withdrawn.  These 
growths  do  not  feel  fluid,  and  are  rarely  circumscribed.  An 
aneurysm  may  cease  to  pulsate  from  consolidation  leading 
to  cure,  or  from  rupture.  Rupture  of  a  large  aneurysm  into 
a  cavity  induces  deadly  pallor,  syncope,  and  rapid  death. 
Rupture  of  an  aneurysm  of  an  extremity  into  the  tissues  is 
made  manifest  by  a  sensation  of  something  breaking,  by 
pain,  by  sudden  increase  in  size,  by  diminution  or  absence 
of  bruit  and  pulsation,  by  absence  of  pulse  below  the  aneu- 
rysm, by  swelling  and  coldness  of  the  limb,  and  by  shock. 

Treatment. — In  inoperable  aneurysms  general,  medical, 
and  dietetic  treatment  must  be  tried.  A  chief  element  in 
treatment  is  rest  in  bed  to  diminish  the  rapidity  and  force  of 
the  circulation  and  favor  fibrinous  deposit.  Tuffnell's  plan  is 
to  reduce  the  heart-beats  by  rest  and  mental  quiet,  and  to 
rigidly  restrict  the  diet  so  as  to  diminish  the  total  amount  of 
blood  and  render  it  more  fibrinous.  Liquids  are  restricted  in 
amount,  and  the  patient  lives  each  twenty-four  hours  upon 
four  ounces  of  bread,  a  very  little  butter,  eight  ounces  of 
milk,  and  three  ounces  of  meat.  Pursue  this  plan  for  sev- 
eral months  if  possible,  or  employ  it  for  several  weeks,  inter- 
mit for  a  short  period,  return  again  to  the  rigid  diet,  and  so 


3l6   DISEASES  AND   INJURIES    OF  HEART  AND    VESSELS. 

on,  over  and  over  again.  There  can  be  no  doubt  that  Tuff- 
nell's  treatment  sometimes  cures  aneurysm  by  decidedly 
lowering  the  blood-pressure.  Valsalva  long  ago  suggested 
rest,  occasional  bleeding,  and  a  diet  just  above  the  point  of 
starvation.  In  many  cases  of  aneurysm  the  patient  may  be 
permitted  to  go  about,  taking  his  time  about  everything 
and  avoiding  work,  worry,  and  excitement.  The  diet  should 
be  low  and  non-stimulating,  and  the  bowels  must  be  main- 
tained in  a  loose  condition. 

Lancereaux  and  others  claim  that  h}'podermatic  injections 
at  some  indifferent  point  of  a  i  or  2  per  cent,  solution  of 
gelatin  in  normal  salt  solution  do  good  in  aortic  and  innomi- 
nate aneurysms.  Lancereaux  injects  250  c.c.  of  the  solution 
into  the  subcutaneous  tissue  of  the  thigh  every  ten  to  fifteen 
days.  From  10  to  20  injections  may  be  given.  The  treat- 
ment is  not  free  from  danger  (two  deaths  have  occurred),  is 
only  to  be  used  for  sacculated  aneurysms,  and  the  gelatin 
solution  is  never  to  be  injected  into  a  vessel  or  about  the 
sac.  A  I  per  cent,  solution  is  safer  than  a  2  per  cent,  solu- 
tion, and  probably  as  efficient.  lodid  of  potassium  in  doses 
of  20  grains  undoubtedly  does  good,  and  not  only  in  syph- 
ilitic cases.  It  seems  to  lower  the  blood-pressure.  Balfour 
taught  that  it  thickened  the  walls  of  the  sac.  Osier  says  it 
relieves  the  pain.  Iron,  acetate  of  lead,  and  ergotin  are 
prescribed  by  some.  Digitalis  is  contraindicated,  as  it  raises 
the  blood-pressure.  S.  Solis  Cohen  has  used  with  some 
success  the  hydrated  chlorid  of  calcium.  Morphin  and 
bromid  of  potassium  are  occasionally  useful  to  tranquillize 
the  circulation,  allay  pain,  or  secure  sleep.  Aconite  and 
veratrum  viride  have  long  been  employed.  Other  expedi- 
ents are :  the  kneading  of  the  sac  to  release  a  clot,  in  the 
hope  that  it  will  plug  the  mouth  of  the  sac  or  the  artery 
beyond  it — this  is  dangerous;  electricity;  electrolysis;  the 
injection  of  an  astringent  liquid ;  the  insertion  of  a  fine  aspi- 
rating-needle  and  the  pushing  through  it  into  the  sac  of  a 
large  quantity  of  silver  wire,  in  the  hope  that  it  will  aid  in 
whipping  out  fibrin.  Some  physicians  have  inserted  needles 
and  horse-hair. 

Even  in  an  operable  case  diet  and  rest  are  of  importance. 
The  patient  should  be  in  bed  for  a  number  of  days  before 
operation,  the  daily  diet  consisting  of  ten  or  twelve  ounces 
of  solid  food  with  a  pint  of  milk.  If  the  circulation  is  very 
active,  use  aconite  and  allay  pain  by  morphin. 

Treatment  by  Pressure. — Instrumental  pressure  is  made  by 
applying  two  Signorini  tourniquets  or  some  specially  devised 


ANEURYSM.  317 

apparatus  to  limit  the  flow  of  blood  through  an  aneurysm 
without  entirely  stopping  it,  the  aneurysmal  sac  being  felt 
to  still  slightly  pulsate.  In  some  situations  Lister's  abdom- 
inal tourniquet  is  applied  ;  in  other  regions  we  may  use  Tuff- 
nell's  compress,  which  is  like  a  spring  truss  and  is  strapped 
in  place.  A  heavy  body  suspended  over  the  artery  and 
resting  part  of  its  weight  upon  the  vessel  has  occasionally 
brought  about  cure.  Compressing  instruments  can  be  worn 
for  from  twelve  to  sixteen  hours  at  a  time ;  usually  they  are 
removed  to  permit  sleep  and  are  reapplied  the  next  day,  and 
so  on  for  several  days.  Before  applying  the  compress  be 
sure  the  sac  is  full  of  blood,  and  render  this  certain  by  ap- 
plying for  a  few  minutes  distal  compression.  This  method 
may  cure,  but  it  is  very  painful.  It  cannot  be  used  suc- 
cessfully in  treating  aneurysm  of  the  axillary,  subclavian,  or 
carotid  artery.     It  aids  in  the  formation  of  an  active  clot. 

Digital  pressure,  made  with  the  thumb  aided  by  a  weight, 
and  maintained  for  many  hours  by  a  relay  of  assistants,  has 
cured  many  cases.  This  method  may  be  used  alone  or  may 
be  used  as  an  accessory  to  instrumental  pressure.  Its  chief 
field  is  in  the  treatment  of  aneurysm  for  which  other  methods 
are  inapplicable  (orbit  and  root  of  neck).  It  entirely  cuts 
off  the  blood  and  promotes  the  formation  of  a  passive  clot. 
If  cure  does  not  take  place  in  three  days,  abandon  pressure. 
It  must  often  be  abandoned  far  earlier  because  of  pain. 

Direct  pressure  upon  the  sac  has  been  used  in  aneurysm 
of  the  popliteal  artery,  the  pressure  being  obtained  by  flexing 
the  leg  ;  and  in  aneurysm  of  the  brachial  artery  pressure  has 
been  applied  at  the  bend  of  the  elbow  by  flexing  the  elbow. 
The  pressure  of  a  hollow  rubber  ball  has  been  used  in  aneu- 
rysm of  the  subclavian. 

Rapid  pressure  completely  arrests  the  passage  of  blood 
through  the  sac  for  a  limited  time,  and  is  applied  while  the 
patient  is  under  the  influence  of  an  anesthetic.  Take,  for 
example,  a  case  of  popliteal  aneurysm ;  the  patient  is  placed 
under  ether;  two  Esmarch  bandages  are  used,  one  being  put 
on  the  limb  from  the  toes  to  the  lower  Hmit  of  the  aneurysm, 
and  the  other  from  the  groin  down  to  the  upper  limit  of  the 
sac,  and  the  Esmarch  band  is  fastened  above  the  upper 
bandage.  This  procedure  stagnates  the  blood  both  in  the 
veins  and  in  the  arteries,  the  sac  remaining  full  of  blood. 
Pressure  is  thus  maintained  for  three  or  four  hours,  and  on 
removing  the  Esmarch  apparatus  a  tourniquet  is  put  on  the 
artery  above  the  aneurysm  and  partly  tightened  to  Hmit 
the  amount  of  blood    passing   through    and    thus    prevent 


3l8   DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

the  washing  away  of  clot.  This  method  of  rapid  pressure 
sometimes  cures  by  formng  a  passive  clot,  but  it  sometimes 
results  in  gangrene.     It  was  devised  by  John  Reid. 

Operative  Treatment :  By  the  Ligature. — Ligation  of  the 
main  artery  is,  as  a  rule,  the  best  procedure.  The  methods 
of  ligation  are — (i)  the  method  of  Antyllus  ;  (2)  the  method 
of  Anel ;  (3)  the  method  of  Hunter  ;  (4)  the  method  of  War- 
drop;  and  (5)  the  method  of  Brasdor. 

In  the  inethoii  of  Antyllus  (Fig.  69),  the  sac  itself  is 
attacked.  The  artery  is  ligated  immediately  above  and 
below  the  sac,  the  sac  is  opened  and  its  contents  turned 
out,  or  the  sac  is  extirpated.  This  method  is  of  the  greatest 
use  for  traumatic  aneurysms.  Syme  suggested  many  years 
ago  that  extirpation  was  the  proper  operation  for  aneurysm 
of  the  gluteal,  iliac,  carotid,  and  axillary  arteries.  In  some 
cases  it  is  the  best  method.  If  the  wall  of  the  blood-vessel 
is  diseased  beyond  the  aneurysm,  the  above  method  should 
not  be  used,  because  it  is  not  wise  to  apply  ligatures  to  dis- 
eased areas  of  the  vessel. 

The  Method  of  Anel. — In  Anel's  method  the  artery  is 
ligated  above  the  sac,  and  so  close  to  it  that  there  are  no 
anastomatic  branches  between  the  sac  and  the  ligature  (Fig. 


Fig.  69. — Old  operation  of  Antyllus  for  aneu- 
rysm {Am.  Text-Book  of  Surgery). 


Fig.  70. — Anel's  operation  for  aneurysm  {Am. 
Text-Llook  of  Surgery). 


70).  It  is  used  only  for  traumatic  aneurysms,  and  is  never 
employed  when  the  vessel  is  diseased  beyond  the  aneurysm. 
The  Method  of  Hunter. — This  operation,  which  is  the 
modern  method  of  ligation,  was  devised  by  the  illustrious 
John  Hunter.  He  recognized  the  fact  that  the  vessel  adja- 
cent to  an  aneurysm  was  apt  to  be  diseased,  and  he  discov- 
ered the  anastomotic  circulation.  Putting  together  these 
two  facts  he  devised  the  operation  which  goes  by  his  name. 
It  consists  in  applying  a  ligature  between  the  heart  and  the 
aneurysm,  but  so  far  above  the  sac  that  collateral  branches 
are  given  off  between  it  and  the  point  of  ligation  (Fig.  71). 
This  operation,  which  is  done  upon  a  healthy  area,  does  not 
permanently  cut  off  all  blood,  but  so  diminishes  the  force  and 
frequency  of  the  circulation  that  an  active  clot  forms  within 


ANEURYSM. 


319 


the  sac.  Thus  is  lessened  the  danger  of  secondary  hemor- 
rhage and  of  gangrene.  It  is,  in  the  majority  of  cases,  the 
proper  operation  for  aneurysm.  In  some  cases  pulsation 
does  not  return  after  tightening  the  ligature ;  in  most  cases, 
however,  it  reappears  for  a  time  after  about  thirt}'-six  hours, 
but  is  weak  from  the  start,  constantly  diminishes,  and  finally 
disappears  permanenth'.  Previous  prolonged  compression 
by  enlarging  the  collateral  branches  permits  strong  pulsa- 
tion to  soon  recur  after  ligation,  and  thus  militates  against 
cure ;  hence  it  is  a  bad  plan  to  use  pressure  in  cases  admit- 
ting of  ligation,  and  in  which  the  success  of  pressure  is  very 
doubtful.  Occasionally  after  Hunter's  operation  the  sac  sup- 
purates, producing  symptoms  like   those  of  abscess.     Sup- 


FiG.  71. — Hunter's  method  of  ligating  for  aneurysm  :  a,  the  aneurysm  ;  b,  the  point  of 
ligation ;  c,  the  branches  between  the  aneurysm  and  the  ligature.  The  arrow  shows  the 
direction  of  the  blood-current. 


puration  may  occur  between  the  first  and  thirty-second  week 
after  ligation.^  When  pus  forms  open  freely  as  we  would 
open  an  abscess,  and,  if  no  blood  flows,  treat  as  an  abscess, 
but  have  a  tourniquet  loosely  applied  for  several  days  ready 
to  screw  up  at  the  first  sign  of  danger.  If  hemorrhage  occurs, 
tie  the  vessel  above  and  below  the  aneurysm,  open  the  sac, 
and  pack  with  iodoform  gauze.  If  bleeding  recurs,  there  is  no 
use  reapplying  the  ligature  and  there  is  little  use  tying  higher 
up.  If  dealing  with  an  arm,  try  the  application  of  a  ligature 
higher  up ;  if  dealing  with  a  leg,  amputate  at  once. 

Distal  Ligation. — When  an  aneurysm  is  so  near  the  trunk 
that  Hunter's  operation  is  impracticable,  or  when  the  artery 
on  the  cardiac  side  of  the  tumor  is  greatly  diseased,  distal 
ligation  may  be  employed.  Distal  ligation  forms  a  barrier 
to  the  onflow  of  blood,  collateral  branches  above  the  aneu- 
rysm enlarge,  the  blood-current  is  gradually  diverted,  and 
a  clot   may  form   within   the   aneur)'sm.     Distal   ligation   is 

^  See  the  case  described  by  Sir  Astley  Cooper. 


320   DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 


used  in  some  aneurysms  of  the  aorta,  iliacs,  innominate 
carotids,  and  subclavians.  It  occasionally  causes  rupture  of 
the  sac  of  the  aneurysm. 

TJie  operation  of  Brasdor  consists  in  tying  the  main  trunk 
some  little  distance  below  the  aneurysm  (Fig.  72).  It  com- 
pletely arrests  circulation  in  the  sac. 

The  operation  of  Wardrop  consists  in  tying  one  of  the 
branches  of  the  artery  below  the  aneurysm.  Wardrop 
originally  advocated  ligation  at  a  point  where  there  was 
no  intervening  branch  between  the  sac  and  the  ligature. 
Later  he  advocated  ligation  when  there  was  an  intervening 
branch.  Since  then  it  is  the  custom  to  consider  Wardrop's 
operation  to  be  the  ligation  of  one  branch  below  the  aneu- 
rysm, as  shown  in  Fig.  73.  The  circulation  is  but  partially 
arrested  by  Wardrop's  operation.  An  X-ray  picture  should 
be  taken  in  every  case  of  aortic  aneurysm.  Such  a  picture 
may  aid  us  in  coming  to  a  conclusion  as  to  which  vessel  or 
vessels  to  tie. 

After  ligating  for  aneurysm  by  any  of  these  methods, 
elevate  the  limb,  keep  it  warm,  and  subdue  arterial  excite- 


FlG.  72. — Brasdor's  operation  (Holmes).     FiG.  73.— Wardrop's  operation  (Holmes). 

ment.  When  gangrene  of  a  limb  follows  ligation,  await  a 
line  of  demarcation,  and  when  it  forms  amputate.  Rupture 
of  the  sac  after  ligation  may  produce  gangrene  or  be  asso- 
ciated with  suppuration,  the  first  condition  demanding  ampu- 
tation, and  the  second  incision  for  drainage. 

Injection  of  coagulating  agents  into  the  sac  (ergot,  per- 
chlorid  of  iron,  etc.)  is  very  dangerous  and  is  to  be  utterly 
condemned.  It  may  lead  to  suppuration,  gangrene,  rupture, 
or  embolism. 

Manipidation  to  break  up  the  clot  was  suggested  by  Sir 


AXECm'SM.  321 

\Vm.  Fergusson,  and  has  been  practised.  The  object  aimed 
at  is  to  have  a  fragment  of  clot  block  up  the  vessel  upon 
the  peripheral  side  of  the  artery  and  act  like  a  distal  liga- 
ture. The  method  is  dangerous  and  should  never  be 
employed. 

Auipiitatioii,  instead  of  distal  ligation,  is  performed  in 
some  perilous  cases  of  subclavian  aneurysm. 

Electrolysis. — An  attempt  may  be  made  to  coagulate  the 
blood  at  once,  or  from  time  to  time  an  endeavor  may  be  made 
to  produce  fibrinous  deposits,  but  the  first  method  is  the 
better.  It  is,  however,  rareh'  possible  to  at  once  occlude 
a  sac,  and  pulsation,  which  is  for  a  time  abolished,  recurs 
as  the  gas  present  is  absorbed.  Use  the  constant  current. 
Take  from  three  to  six  cells  which  stand  in  point  of  size 
between  those  used  for  the  cautery  and  those  used  for  ordi- 
nary medical  purposes.  A  platinum  needle  is  attached  to  the 
positive  pole  and  a  steel  needle  to  the  negative  pole,  each 
needle  being  insulated  by  vulcanite  at  the  spot  where  the 
tissues  will  touch  it.  The  asepticized  needles  are  plunged  into 
the  sac  where  it  is  thick,  and  they  are  kept  near  together. 
The  current  is  passed  for  a  variable  period  (from  half  an 
hour  to  an  hour  and  a  half).  This  operation  is  not  dan- 
gerous. Pressure  stops  the  bleeding.  Electrolysis  often 
ameliorates,  and  sometimes,  though  very  rarely,  cures,  aortic 
aneurysms.^ 

Ac2iprcssiirc  consists  of  the  partial  introduction  of  a  num- 
ber of  ordinary  sewing-needles  into  an  aneurysmal  sac  and 
leaving  them  in  it  for  five  or  six  days  or  more.  Prof 
Macewen  introduces  a  needle,  and  with  it  irritates  the  interior 
of  the  sac  of  an  aneurj-sm,  hoping  thus  to  cause  deposition 
of  leukocytes  and  clot-formation. 

Introditction  of  Wire. — Insert  into  the  sac  a  h}'podermatic 
or  small  aspirating-needle,  and  push  through  the  needle  or 
cannula  a  considerable  quantity  of  aseptic  gold  wire,  Avhich 
is  allowed  to  remain  permanently.  Electrolysis  should  be 
combined  with  the  introduction  of  wire.  This  operation  was 
first  proposed  by  Corradi.  Loreta  and  Barwell  both  inserted 
wire  into  an  aneurysm  before  Corradi,  but  Corradi  inserted 
wire  and  also  used  electricity.  Corradi's  operation  can  be 
used  when  distal  ligation  cannot  be  carried  out,  and  can  be 
used  even  when  the  vessel  is  extremely  atheromatous.  It 
finds  its  chief  use  in  aneurysms  of  the  thoracic  aorta  and 
innominate.  In  some  cases  of  abdominal  aneur}-sm  the 
bell}'  has  been  opened  and  the  operation  carried  out.     Some 

^  See  Jobu  Duncan,  in  Heath's  Dictionary. 
21 


322   DISEASES  AND   EYJURIES    OF  HEART  AND    VESSELS. 

cases  have  been  notably  improved,  and  one  of  Stewart's  cases 
was  apparently  cured. ^  The  operation  is  performed  with 
aseptic  care.  If  the  thoracic  aorta  is  to  be  operated  upon, 
an  anesthetic  is  not  required.  If  the  abdominal  aorta  is  to 
be  wired,  the  patient  must  be  anesthetized.  The  wire  used 
must  have  been  previously  drawn,  so  that  it  will  easily  pass 
through  a  hypodermatic  needle  and  will  coil  up  spirally 
within  the  sac  (Stewart).  The  best  wire  is  of  silver  or  gold. 
It  is  a  great  mistake,  Stewart  says,  to  introduce  a  large 
quantity.  He  considers  that  a  globular  sac  three  inches  in 
diameter  requires  from  three  to  five  feet,  and  a  sac  five  inches 
in  diameter  requires  from  eight  to  ten  feet.  A  hypodermatic 
needle,  insulated  up  to  one-quarter  inch  of  the  point,  is 
carried  into  the  interior  of  the  aneurysm  through  a  fairly 
thick  portion  of  the  sac.  The  required  amount  of  wire  is 
introduced.  The  wire  is  attached  to  the  positive  pole  of  the 
battery.  The  negative  pole  is  fastened  to  a  large  flat  piece 
of  clay  or  a  pad  of  moistened  absorbent  cotton,  and  the 
negative  electrode  is  placed  upon  the  back  or  abdomen. 
The  current  is  turned  on  gradually  until  the  necessary 
strength  is  obtained  (40  to  80  ma.).  When  ready  to  ter- 
minate the  operation  the  current  is  lowered  gradually  to  zero, 
the  needle  is  withdrawn,  the  wire  is  cut  off  close  to  the  skin, 
and  the  end  is  pushed  under  the  skin  and  the  puncture  is 
covered  with  iodoform  collodion.  The  entire  operation 
requires  from  three-quarters  of  an  hour  to  one  and  a  half 
hours.^  A  clot  forms  with  considerable  rapidity  and  expan- 
sile pulsation  may  lessen  or  cease.  The  operation  can  be 
repeated  if  necessary. 

Traumatic  aneurysm  is  a  condition  in  which,  after 
puncture  or  rupture  of  an  artery,  a  sac  has  formed  of  tissue, 
and  if  any  wound  previously  existed,  it  has  healed.  The 
treatment  consists  in  ligation  by  the  method  of  Antyllus,  or 
complete  excision.  When  an  artery  ruptures  and  a  large 
mass  of  blood  is  extravasated  into  the  tissues  no  sac  exists, 
and  it  is  an  error  to  designate  this  condition  as  a  diffuse 
traumatic  aneurysm.  In  traumatic  aneurysm,  a  large,  oblong, 
fluctuating  swelling  is  found.  If  the  rent  is  large,  there  are 
bruit  and  pulsation.  There  is  no  pulsation  in  the  arteries 
below  the  aneurysm,  and  the  limb  is  cold  and  swollen.  The 
skin  is  at  first  of  a  natural  color,  but  becomes  thin  and  purple. 
If  the    main  vein    is   also  ruptured,   or  if  the   rupture   has 

'  D.  D.  Stewart,  in  Phila.  Med.  Jour.,  October  12,  1898. 
2  The  above  description  is  condensed  from  that  of  D.  D.  Stewart,  in  Phila. 
Med.  Jour. ,  November  1 2,  1 898. 


AR  TEH  10 1  'ENO  US  ANE  UR  YSM. 


323 


occurred  into  a  large  joint,  amputate  ;  otherwise  perform  the 
operation  of  Antyllus. 

Arteriovenous  aneurysm  is  an  unnatural  passage-way 
between  a  vein  and  an  artery,  through  which  passage  blood 
circulates.  There  are  two  forms  :  {a)  anmrysnial  varix,  or 
Pott's  aneurysm,  a  vein  and  an  artery  directly  communi- 
cating ;  and  {6)  varicose  aneurysm,  a  vein  and  artery  communi- 
cating 'through  an  intervening  sac.  These  conditions  arise 
usuaUy  from  punctured  wounds,  the  instrument  passing 
through  one  vessel  and  into  the  other,  blood  flowing  into 
the  vein,  the  subsequent  inflammation  gluing  the  two  vessels 
together,  and  the  aperture  failing  to  close  (aneurysmal  varix, 
Fig.  74).  After  the  infliction  of  the  wound  the  two  vessels 
may  separate;  the  blood  continuing  to  flow  from  artery  into 
vein,  and  the  blood-pressure,  by  consolidating  tissue,  form- 
ing a  sac  of  junction  (varicose  aneurysm,  Fig.  75).  Aneu- 
rysmal varix  is  afar  less  grave  disorder  than  varicose  aneurysm. 

Symptoms. — In  aneurysmal  varix  a  swelling  exists  with 
the  characteristic  pulsation,  and  a  loud  whirring  bruit  is 
transmitted  along  the  veins.  The  veins  above  and  below 
the  tumor  are  enlarged,  tortuous,  and  pulsating.  A  distinct 
thrill  is  felt.  Pressure  over  the  tumor  arrests  the  thrill  and 
greatlv  lessens  the  bruit.  The  extremity  is  apt  to  be  swollen 
and  the  parts  are  usually  painful.  When  pressure  on  the 
main  artery  causes    the  entire  disappearance  of  the  tumor, 


Fig.  74. — Plan  of  an  aneurysmal  varix. 


Fig.  75. — Varicose  aneurysm  (Spence). 


the  case  is  one  of  aneurysmal  varix ;  but  if  on  applying  this 
pressure  the  veins  collapse  and  a  distinct  tumor  remains 
which  may  be  emptied  by  direct  pressure,  the  case  is  one  of 
varicose  aneurysm.  If  light  pressure  on  one  spot  stops  both 
murmur  and  thrill,  the  disease  is  aneurysmal  varix.  The 
diagnosis  between  the  two  is  often  impossible. 

Treatment. — Aneurysmal  varix  often  requires  only  palli- 
ative measures,  as  it  does  not  tend  to  rupture,  the  vein 
becoming  thick  and  resistant  and  after  a  time  ceasing  to 
enlarge.  Some  form  of  support  is  used.  If  the  part  is 
painful  or  the  vein  is  in  danger  of  rupture,  tie  the  artery 


324  DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

above  and  below  the  opening,  or  ligate  both  vessels  and 
excise  them  for  some  little  distance  each  side  of  the  point  of 
trouble.  Varicose  aneurysm  requires  the  use  of  the  plans 
ordinarily  adopted  in  treating  aneurj^sm  (compression,  etc.). 
If  these  fail,  tie  the  artery  above  and  below  the  opening 
without  opening  the  sac,  or  excise  the  involved  areas  of  vein 
and  artery,  and  also  the  sac. 

Cirsoid  aneurysm,  or  aneurysm  by  anastomosis, 
consists  in  great  dilatation  with  pouching  and  lengthening  of 
one  or  several  arteries.  The  disease  progresses  and  after  a 
time  involves  the  veins  and  capillaries.  The  walls  of  the 
arteries  become  thin  and  the  vessels  tend  to  rupture.  Cir- 
soid aneurysm  is  met  with  upon  the  forehead  and  scalp  of 
young  people,  where  it  sometimes  takes  origin  from  a  nevus. 

Symptoms. — There  is  a  pulsating  mass,  irregular  in  out- 
line, composed  of  dilated,  elongated,  and  tortuous  vessels  that 
empty  into  one  another.  The  mass  is  soft,  can  be  inuch 
reduced  by  direct  pressure,  and  is  diminished  by  compression 
of  the  main  artery  of  supply.  A  thrill  and  a  bruit  exist. 
Pregnancy  and  puberty  cause  rapid  growth  of  a  cirsoid 
aneurysm. 

Treatment. — In  treating  a  cirsoid  aneurysm  the  ligation 
of  the  larger  arteries  of  supply  is  a  wretched  failure.  Subcu- 
taneous ligation  at  many  points  of  the  diseased  area  has 
effected  cure  in  some  cases,  but  it  has  failed  in  more. 
Direct  pressure  is  also  entireh^  useless.  Ligation  in  mass 
has  been  successful.  Destruction  by  caustic  has  its  advo- 
cates. Electropuncture  with  circular  compression  of  the 
arteries  of  supply  has  once  or  twice  effected  a  cure.  Injec- 
tion of  astringents  has  been  recommended.  Verneuil  ligated 
the  afferent  arteries,  incised  the  tissues  around  the  tumor, 
and  sunk  a  constricting  ligature  into  the  cut.  The  proper 
method  of  treatment  is  excision  after  subcutaneous  or  open 
ligation  of  every  accessible  tributary  of  supply.^ 

Wounds  of  Arteries  are  divided  into  contused,  incised, 
lacerated,  punctured,  and  gunshot-wounds,  and  vascular 
ruptures. 

Contused  and  Incised  Wounds. — A  contusion  ma}-  de- 
stroy vitality  and  be  followed  by  sloughing  and  hemorrhage. 
A  contusion  may  rupture  a  blood-vessel,  and  is  especially 
apt  to  do  so  if  the  vessel  is  diseased.  Blood  is  at  once 
effused  at  the  seat  of  rupture.  If  an  artery  is  ruptured,  there 
may  or  may  not  be  a  bruit  and  pulsation  over  the  seat 
of  rupture,  pulse   is   absent  below,  and  the  leg  below  the 

1  x\ndeison,  in  Heath's  Dictionary  of  Practical  Surgery. 


U'OCWDS   OF  ARTERIES.  325 

injury  swells  and  becomes  cold.  If  a  large  vein  ruptures, 
a  blood  tumor  forms,  which  does  not  pulsate  and  has  no 
bruit,  and  the  limb  below  becomes  intensely  edematous. 
Gangrene  is  apt  to  follow  the  rupture  of  a  main  blood- 
vessel of  an  extremity.  A  contusion  may  rupture  the 
internal  and  middle  coats  of  an  artery,  the  external  coat 
remaining  intact.  When  this  happens  the  internal  coat 
curls  up  and  the  middle  coat  contracts  and  retracts,  the 
blood-stream  is  arrested,  and  a  large  clot  forms  within  the 
artery.  If  the  clot  blocks  up  many  collaterals,  gangrene  will 
follow,  and,  as  has  been  pointed  out,  the  gangrene  will  not 
be  preceded  by  swelling  at  the  seat  of  injury,  which  always 
occurs  if  a  vessel  is  ruptured.  A  contused  wound  may  do 
little  damage,  or  it  may  produce  gangrene  from  thrombosis, 
or  it  may  cause  secondary  hemorrhage.  In  an  incised 
wound   of    an    artery  there    is    profuse    hemorrhage.     The 


1..  -,        ^. 


Fig.  76 — Clots  formed  after  division  of  an  arterj' :    i,  2,  3,  outer,  middle,  and  inner  coats ; 
c,  c,  branches  ;   d,  d,  internal  clot ;    e,  e,  external  clot. 

artery  after  a  time  is  apt  to  contract  and  retract,  bleeding  being 
thus  arrested.  A  transverse  wound  causes  profuse  bleed- 
ing, but  there  is  a  better  chance  for  natural  arrest  than  in 
an  oblique  or  in  a  longitudinal  wound.  The  clot  which 
forms  wuthin  a  cut  artery  is  known  as  the  "  internal  clot ; " 
it  reaches  as  high  as  the  first  collateral  branch,  and  subse- 
quently is  replaced  by  fibrous  tissue,  which  permanently 
obliterates  the  vessel,  and  converts  it  into  a  shrunken  fibrous 
cord.  Between  the  vessel  and  its  sheath,  over  the  end  of 
the  vessel,  and  in  the  surrounding  perivascular  tissues  is  the 
"  external  clot "  (Fig.  76). 

A  lacerated  wound  of  an  arter}'  causes  little  primary 
hemorrhage.  The  internal  coat  curls  up,  the  circular  mus- 
cular fibers  of  the  media  contract  upon  it,  the  longitudinal 
fibers  retract  and  draw  the  vessel  within  the  sheath,  and  the 
external  coat  becomes  a  cap  over  the  orifice  of  the  vessel 


326   DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

— all  of  these  conditions  favor  clotting.  The  vessel-wall 
is  so  damaged  that  secondary  hemorrhage  is  usual. 

Punctured  "Wounds. — In  punctured  wounds  primary 
hemorrhage  is  slight  unless  a  large  vessel  is  punctured. 
Secondary  hemorrhage  is  not  common.  Traumatic  aneu- 
rysm and  arteriovenous  aneurysm  are  not  unusual  results. 

Gunshot-wounds  are  apt  to  be  contusions  which  may 
eventuate  in  sloughing  and  secondary  hemorrhage  or  throm- 
bosis and  gangrene.  A  shell-fragment  makes  a  lacerated 
wound.  A  modern  rifle-bullet  makes  a  clean-cut  division 
of  an  artery.  Secondary  hemorrhage  after  gunshot-wounds 
is  most  likely  to  occur  during  the  third  week  after  the  injury. 
Partial  rupture  of  an  artery  may  cause  sloughing  and  sec- 
ondary hemorrhage,  thrombosis  and  gangrene,  or  aneurysm. 
A  complete  rupture  constitutes  a  lacerated  wound,  and  is  a 
condition  accompanied  by  dififuse  hemorrhage  into  the  tissues. 

Wounds  of  veins  are  classified  as  are  wounds  of  arteries. 
The  symptom  of  any  vascular  wound  is  hemorrhage. 

I.  Hemorrhage,  or  Loss  of  Blood. 

Hemorrhage  may  arise  from  wounds  of  arteries,  veins, 
or  capillaries,  or  from  wounds  of  the  three  combined.  In 
arterial  hemorrhage  the  blood  is  scarlet  and  appears  in  jets 
from  the  proximal  end  of  the  vessels,  which  jets  are  syn- 
chronous with  the  pulse-beats ;  the  stream,  however,  never 
intermits.  The  stream  from  the  distal  end  is  darker  and  is 
not  pulsatile.  Venous  hemorrhage  is  denoted  by  the  dark 
hue  of  the  blood  and  by  the  continuous  stream.  In  capil- 
lary hemorrhage  red  blood  wells  up  like  water  from  a 
squeezed  sponge,  and  the  color  is  between  the  bright  red  of 
arterial  blood  and  the  dark  color  of  venous  blood. 

In  subcutaneous  hemorrhage  from  rupture  of  a  large 
blood-vessel  there  are  great  swelling,  cutaneous  discoloration, 
and  systemic  signs  of  hemorrhage.  If  a  main  artery  rupt- 
ures in  an  extremity,  there  is  no  pulse  below  the  rupture, 
and  the  limb  becomes  cold  and  swollen.  At  the  seat  of 
rupture  a  large  fluctuating  swelling  forms,  and  sometimes 
there  are  bruit  and  pulsation.  If  a  vein  ruptures  in  an 
extremity,  a  large,  soft,  non-pulsatile  swelling  arises,  there 
is  no  bruit,  and  intense  edema  occurs  below  the  seat  of 
rupture.  Profuse  hemorrhage  induces  constitutional  symp- 
toms, and  death  may  occur  in  a  few  seconds.  Loss  of  half 
of  the  blood  will  usually  cause  death  (from  four  to  six 
pounds),  though  women  can  stand  the  loss  of  a  greater  rela- 


hemorrhagb:.  327 

tive  proportion  of  blood  than   men.     Young  children,  old 
people,   individuals  exhausted  by    disease,  drunkards,  suf- 
ferers from  Bright's  disease,  diabetes,  and  sepsis  stand  loss 
of  blood  very  badlv.     Generally,  after  the  bleeding  has  gone 
on  for  a  time  syncope  occurs,  which  is   Nature's  effort  to 
arrest  hemorrhage,  for  during  this  state  the  feeble  cuxulation 
and  the  increased  coagulability  of  blood  give  time  for  the 
formation  of  an  external  clot.     When  reaction  occurs  the 
clot  may  hold  and  be  reinforced  by  an  internal  clot,  or  it 
may  be  washed  away  with  a  renewal  of  bleeding  and  syn- 
cope.    These  episodes  may  be  repeated  until  death  super- 
venes.    Nausea  exists.     There  may  be  regurgitation  frorn 
the  stomach,  and  vertigo  is  present.     There  is  dimness  of 
vision  or  everything  looks  black ;  black  specks  float  before 
the  eyes  (muscse  volitantes),  or  the  patient  sees  flashes  of 
licrht   or    colors.      There   is    a   roaring    sound    in    the   ears 
(ttnnitus  aurium).     The  patient  is  restless  and  tosses  to  and 
fro,  and  great  thirst  is  complained  of.     The  mind  may  be 
clear,  but  delirium   is   not   unusual,  and  convulsions   often 
occur.    After  a  profuse  hemorrhage  an  individual  is  intensely 
pale  and  his  skin  has  a  greenish  tinge  ;  the  eyes  are  fixed  in 
a  glassy  stare  and  the  pupils  are  wddely  dilated,  and  react 
slowly 'to  light;  the  respirations  are  shallow  and  sighing; 
the  skin  is  covered  with  a  cold  sweat;  the  legs  and  arms  are 
extremely  cold  ;  the  pulse  is  soft,  small,  compressible,  flutter- 
ing, or  often  cannot  be  detected;  the  heart  is  very  weak  and 
fluttering  ;  there  is  muscular  tremor ;  the  patient  tosses  about, 
and  asks  often  and  in  a  feeble  voice  for  water.    The  suffering 
from  thirst  is  terrible  and  no  amount  of  water  gives  relief. 
There  is  often  dreadful  dyspnea,  and  a  man  who  is  bleeding  to 
death  grasps  at  his  chest,  rises  up  upon  his  elbow,  and  then 
falls  back  in  a  dead  faint.     Usually  reaction  occurs,  though 
the  patient  is  obviously  weaker  than  before ;  again  a  faint 
may  happen,  and  so  there  is  fainting  spell  after  fainting  spell 
until  death  ensues.     Convulsions  frequently  precede  death. 
In   hemorrhage    the    hemoglobin    is   greatly   diminished   in 
amount.   In  an  interabdominal  hemorrhage  the  above  symp- 
.  toms  are  noted,  and,  except  in  splenic  hemorrhage,  blood 
crathers  in  both  loins,  and  dulness  on  percussion  exists  which 
gradually  rises  and  shifts  as  the  patient's  position  is  shifted 
The  blood  also  gathers  in  the  rectovesical  pouch  in  the  male, 
and  in  the  recto-uterine  pouch  in  the  female,  and  may  be 
detected  by  digital  examination.     If  the  spleen  is  wounded, 
the  blood  clots  quickly,  and  an  area  of  dulness,  which  does 
not  shift  and  which  progressively  increases,  is  noted  m  the 


328   DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

splenic  region.  When  such  a  dangerous  condition  is  due  to 
a  visible  hemorrhage,  a  large  vessel  in  an  extremity  having 
been  divided,  temporarily  arrest  bleeding  by  digital  pressure 
in  the  wound,  or  the  application  of  an  Esmarch  band  above 
the  wound  (if  the  bleeding  is  arterial).  In  some  cases  forced 
flexion  is  used.  Lower  the  head,  and  have  compression 
made  upon  the  femorals  and  subclavians,  so  as  to  divert 
more  blood  to  the  brain,  or  bandage  the  extremities  (auto- 
transfusion).  Apply  artificial  heat.  Inject  by  hyperdermo- 
clysis  the  normal  salt  solution  (lo  to  i6  ounces)  into  the 
cellular  tissue  of  the  buttock,  or  infuse  the  salt  solution  into 
a  vein,  inject  ether  hypodermatically,  then  brandy,  and  then 
strychnin  in  doses  of  gr.  2V-  Atropin,  digitalis,  and  morphin 
are  recommended.  Give  enemata  of  hot  coffee  and  brandy. 
Apply  mustard  over  the  heart  and  spine.  Lay  a  hot-water 
bag  over  the  heart.  As  •  soon  as  reaction  is  established, 
arrest  the  bleeding  permanently  by  the  ligature.  In  intra- 
abdominal hemorrhage  open  the  abdomen,  in  spite  of  the 
weakened  condition  of  the  patient,  and  arrest  the  bleeding. 
In  hemorrhage  into  the  belly  there  is  no  way  of  temporarily 
arresting  it  before  bringing  about  reaction  and  permanently 
arresting  it.     The  radical  course  must  be  followed  at  once. 

A  severe  hemorrhage  is  apt  to  be  followed  by  fever,  due 
to  the  absorption  of  fibrin  ferment  from  extravasated  blood 
and  its  action  upon  a  profoundly  debilitated  system.  In  this 
form  of  fever  there  are  most  intense  thirst,  violent  headache, 
dimness  of  vision,  great  restlessness,  often  mental  wandering, 
with  a  very  frequent,  weak,  and  fluttering  heart.  After  a 
severe  hemorrhage  leukocytes  are  increased,  not  only  rela- 
tively but  absolutely.  Red  corpuscles  are  diminished  both 
relatively  and  absolutely.  Hemoglobin  diminishes ;  many 
of  the  corpuscles  become  irregular  and  microcytes  are 
noticed. 

In  treating  a  patient  who  has  thoroughly  reacted  after  a 
severe  hemorrhage,  apply  cold  to  the  head  to  prevent  serous 
effusion  into  the  brain.  Aconite,  morphin,  and  neutral 
mixture  are  given  by  the  mouth.  Fluids  and  ice  are  grate- 
ful. Frequently  sponge  the  skin  with  alcohol  and  water  (S. 
W.  Gross).  Milk  punch,  koumiss,  and  beef-peptonoids  are 
given  at  frequent  intervals. 

Hemostatic  agents  comprise  (i)  the  ligature;  (2)  torsion  ; 
(3)  acupressure  ;  (4)  elevation  ;  (5)  compression  ;  (6)  styptics  ; 
(7)  the  actual  cautery ;  and  (8)  forced  flexion  of  Hmbs. 

The  ligature  was  known  to  the  ancients,  but  was  redis- 
covered by  Ambroise  Pare.     The  ligature  may  be  made  of 


HEMORRHAGE. 


329 


silk,  floss-silk,  or  catgut.  Whatever  material  is  used  must, 
of  course,  be  rendered  aseptic.  The  ligatures  should 
be  about  ten  inches  long.  The  vessel  to  be  tied  must  be 
dra:\vn  out  with  forceps  and  separated  for  a  short  distance 
from  its    sheath,  but    must    not  be  separated  to    any  con- 


FiG.  77. — Curved  hemostatic  forceps. 

siderable  extent ;  to  do  so  may  lead  to  necrosis  of  the  vessel 
and  secondary  hemorrhage.  The  hemostatic  forceps  (Figs,  jj, 
78).  is  in  most  cases  a  better  instrument  than  the  tenaculum 
(Fig  79).  The  tenaculum  makes  a  hole  in  the  vessel,  and 
sometimes  a  slit-like  tear.    A  portion  of  this  opening  may  re- 


Straight  hemostatic  forceps. 


main  back  of  the  tied  ligature,  the  vessel  may  retract  a  little,  or 
the  ligature  may  slip  slightly,  and  bleeding  may  occur.  When 
the  artery  lies  in  dense  tissues  or  is  retracted  deeply  in  muscle 
or  fascia,  the  tenaculum,  when  carefully  used,  is  the  better  in- 
strument.   The  ligature  is  tied  in  a  reef-knot  (Fig.  80),  not  in  a 


330   DISEASES  AXD   INJURIES    OF  HEART  AND    VESSELS. 

granny-knot  (Fig.  8i),  or  in  a  surgeon's  knot  (Fig.  82).  It  is 
often  the  purpose  of  the  surgeon  to  divide  the  internal  and  mid- 
dle coats  of  the  vessel,  and  if  such  is  his  desire  the  first  knot 
is  firmly  tied.    The  second  knot  must  not  be  tied  too  tightly, 


Fig.  79. — Tenaculum. 

or  it  will  cut  the  ligature.  The  ligature  must  not  be  jerked 
as  it  is  being  tied,  and  both  ends  are  to  be  cut  off  close  to  the 
knot.  Both  ends  of  a  divided  vessel  should  be  ligated  (Fig. 
84).    If  a  vessel  is  atheromatous,  it  is  not  desirable  to  divide  the 


I. — Method    of    tying   square 
or  reef-knot. 


Fig.   81. — Method   of    tying  granny 
knot. 


internal  and  middle  coats.  In  this  case  a  ligature  should  be 
applied  firmly  rather  than  tightly,  and  another  ligature  should 
be  put  on  above  it,  or  ligation  can  be  effected  by  the  stay 
knot.    If  an  artery  is  incompletely  divided,  a  ligature  should  be 


Fig.  82. — Method  of  tying  surgeon's  knot. 


applied  on  each  side  of  the  wound,  and  the  vessel  divided 
between  the  ligatures.  If  a  large  vein  is  slightly  torn,  try 
to  pinch  up  the  vein-walls  around  the  rent  and  apply  a  liga- 
ture (lateral  ligature,  Figs.  84,  93).  If  a  vein  is  longitudinally 
torn,  close  the  wound  with  a  Lembert  suture  of  silk(Ricard  and 


HEMORRHA  GE. 


331 


Niebergall  have  done  this  successfulh-).  jMurphy  of  Chicago 
has  recently  shown  that  longitudinal  wounds  or  small  lateral 
wounds  of  either  veins  or  arteries  can  be  closed  successfully 
with  silk  sutures,  and  if  a  transverse  wound  includes  more 
than  one-third  of  the  circumference  of  the  vessel,  after  the 
vessel  is   complete!}-  divided   the    ends   can   be   successfully 


,^ 


Fig.  S3. — Hagedorn's   needles 


Fig.  84. — Method  of  controlling  hemorrhage  by 
ligature  (after  Esmarch)  :  a,  arterj-  ligated ;  b, 
lateral  ligature  of  vein. 


united.^  In  extensive  tears  tie  the  vein  in  two  places,  and  cut 
the  vessel  between  the  ligatures.  If  the  bleeding  comes  from 
an  arter}-  very  close  to  its  point  of  origin,  tie  the  main  trunk 
as  well  as  the  bleeding  branch,  otherwise  the  clot  formed 
will  be  very  short  and  secondary  hemorrhage  will  be  ine^-- 
itable.  When  the  parts  about 
an  arter}^  are  so  thickened  that 
the  arteiy  cannot  be  drawn  out, 
arm  a  Hagedorn  needle  (Fig. 
Z"^  with  catgut  and  so  pass 
the  latter  around  the  vessel 
that  the  catgut  will  include  the 
vessel  with  some  of  the  sur- 
rounding tissue,  and  tie  the 
ligature  (Fig.  85).  This  method 
is  known  as  the  apphcation  of 

a  suture-ligature,  and  is  pursued  in  necrosis,  atheroma,  scar- 
tissue,  sloughing,  etc.      Never  include  a  nerve  of  an\'  size 

^  See  Medical  Record,  Jan.  i6,  1S97. 


-Arrest  of  hemorrhage  by 
ing  a  suture-ligature. 


332   D/SEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

in   the    ligature.       If  this   mode  of  hgation    fails,   try    acu- 
pressure. 

Torsion. — Torsion  was  practised  by  the  ancients,  but  was 
reintroduced  in  modern  times,  particularly  by  Amussat, 
Velpeau,  Syme,  and  Bryant  of  London.  By  means  of  tor- 
sion the  internal  and  middle  coats  are  ruptured,  and  the 
external  coat  is  twisted.  The  middle  coat  retracts  and  con- 
tracts, and  the  inner  coat  inverts  into  the  lumen  of  the  artery. 
It  is  a  safe  procedure,  and  is  practised  upon  vessels  as  large 
as  the  femoral  by  many  surgeons  of  high  standing.  Before 
the  days  of  asepsis  torsion  possessed  the  signal  merit  of  not 
introducing  possible  infection  in  ligatures.  At  the  present 
time  it  offers  no  particular  advantage.  It  is  no  quicker  than 
the  ligature,  and  damages  the  vessel  so  much  that  necrosis 
may  occur.     It  cannot  be  used  if  the  vessels  are  diseased. 


Fig.  86. — Method  of  controlling  hemorrhage  by  torsion. 

In  what  is  known  as  free  torsion  the  vessel  is  grasped,  drawn 
out  and  twisted  until  the  free  end  of  the  vessel  is  twisted  off. 
Limited  torsion  is  more  often  used.  The  vessel  is  drawn  out 
of  its  sheath  by  a  pair  of  forceps  held  horizontally,  and  is 
grasped  a  little  distance  above  its  extremity  by  another  pair 
of  forceps  held  vertically  (Fig.  86).  The  first  instrument 
is  used  to  twist  the  artery  six  to  eight  times. 

Acupressure  is  pressure  with  a  pin.  The  method  of  hemo- 
stasis  by  acupressure  was  devised  by  Sir  James  Y.  Simpson. 
A  pin  is  simply  passed  under  a  vessel  (transfixion),  leaving 
a  little  tissue  on  each  side  between  the  pin  and  vessel.  A 
needle  can  be  passed  under  a  vessel,  and  a  wire  be  thrown 
over  the  needle  and  twisted  (circumclusion).  The  needle 
can  be  inserted  upon  one  side,  passed  through  half  an  inch 
of  tissues  up  to  the  vessel,  be  given  a  quarter-twist,  and  be 
driven  into  the  tissues  across  the  artery  (torsoclusion).  Some 
tissue  may  be  picked  up  on  the  needle,  folded  over  the  vessel, 
and  pinned  to  the  other  side  (retroclusion).  Acupressure  is 
occasionally  used  to  arrest  hemorrhage  in  inflamed  or  ather- 


JIEMORKHA  GE. 


333 


omatous  vessels,  in   sloughing  wounds,  in  scar-tissue,  and 
when  a  ligature  will  not  hold. 

Elevation  is  used  as  a  temporary  expedient  or  in  associa- 
tion with  some  other  method.  It  is  of  use  in  a  wound  of  a 
bursa,  in  bleeding  from  a  ruptured  varicose  vein,  and  is  fre- 
quently used  with  compression. 

Co7)ipressioii  is  either  direct  or  indirect — that  is,  in  the 
wound  or  upon  its  artery  of  supply.  In  the  removal  of  the 
upper  jaw  arrest  bleeding  by  plugging.  In  injury  of  a  cere- 
bral sinus,  plug  with  gauze.  Compression  and  hot  water 
(ii5°-i20°  F.)  will  stop  capillary  bleeding.  A  graduated 
compress  was  formerly  recommended  in  hemorrhage  from 
the  palmar  arch.  A  compress  will  arrest  bleeding  from 
superficial  veins.  The  knotted  bandage  of  the  scalp  will 
arrest  bleeding  from  the  temporal  artery.  Long-continued 
pressure  causes  pain  and  inflammation. 

Indirect  compression  is  used  to  prevent  hemorrhage  or  to 
temporarily  arrest  it.  It  may  be  effected  by  encircling  a 
limb  above  a  bleeding  point  with  an  Esmarch  band  or 
by  applying  a  tourniquet  or  an  improvised  tourniquet  (Fig. 
87).  It  may  also  be  effected  b}' 
digital  compression.  Digital  com- 
pression can  be  kept  up  only  a 
few  minutes  by  one  person,  but 
a  relay  of  assistants   can  carrj^  it 


Fig.  87. — Impromptu  tourniquet  for  compressing  an 
artery  with  a  handkerchief  and  a  stick. 


Fig.  88. — Handle  of  door-key, 
padded. 


out  for  a  considerable  time.  In  compressing  the  subclavian, 
wrap  a  key  as  shown  in  Fig.  88,  and  compress  the  artery 
against  the  outer  surface  of  the  first  rib.  The  shoulder 
must  be  depressed  and  pressure  applied  in  the  angle  be- 
tween the  posterior  border  of  the  sternocleidomastoid  and 
the  upper  border  of  the  clavicle.  The  direction  of  the  press- 
ure should  be  downward,  backward,  and  inward. 

The    brachial    artery    can    be    compressed    against    the 
humerus.     In  the  upper  part  of  the  course  of  the  artery  the 


334   DISEASES  AND   INJURIES    OF  HEART  AND    VESSELS. 

pressure  should  be  from  within  outward  (Fig.  89),  in  the 
lower  part  from  before  backward  (Fig.  90).  The  abdominal 
aorta  can  be  compressed  by  Macewen's  method.  The  com- 
mon iliac  can  be  compressed  through  the  rectum  by  means 


. — Digital  compression  of  the  brachial  artery. 


of  a  round  piece  of  wood  known  as  Davy's  lever.  The 
femoral  artery  can  be  compressed  just  below  Poupart's  liga- 
ment   against   the    psoas    muscle    and    head   of    the    femur 


Fig.  90. — Digital  compression  of  the 
brachial  artery. 


Fig.  91. — Digital  compression  of  the 
femoral  artery. 


(Fig.  91).  The  pressure  should  be  directly  backward.  In 
the  middle  third  of  the  thigh  digital  compression  is  unsatis- 
factory, and  a  tourniquet  should  always  be  used  or  an 
Esmarch  band  be  employed. 


HEMORKHA  GE.  335 

Forced  flexion  is  a  variety  of  indirect  compression  intro- 
duced by  Adelmann.  It  will  arrest  bleeding  below  the 
point  compressed,  but  soon  becomes  intensely  painful. 
Forced  flexion  can  be  maintained  by  bandages.  Brachial 
hyperflexion  is  maintained  by  tying  the  forearm  to  the  arm. 
It  is  often  associated  with  the  use  of  a  pad  in  front  of  the 
elbow.  Genuflexion  is  kept  up  by  tying  the  foot  to  the 
thigh.  It  is  increased  in  efficiency  by  placing  a  pad  in  the 
popliteal  space. 

Styptics. — Chemicals  are  now  rarely  used  to  arrest  hem- 
orrhage. In  epistaxis  we  may  pack  with  plugs  of  gauze 
saturated  with  a  10  per  cent,  solution  of  antipyrin.  In  bleed- 
ing from  a  tooth-socket  freeze  with  chlorid  of  ethyl  spray, 
and  then  pack  with  gauze  soaked  with  10  per  cent,  solution 
of  antipyrin  or  pack  with  styptic  cotton  (absorbent  cotton 
soaked  in  Monsel's  solution  and  dried).  A  bit  of  cork  may 
be  forced  into  the  socket.  In  bleeding  from  an  incised 
urinary  meatus  pack  with  styptic  cotton  and  compress  the 
lips  of  the  meatus.  Cold  water,  chlorid  of  ethyl  spray,  and 
ice  act  as  styptics  by  producing  reflex  vascular  contraction. 
Hot  water  produces  contraction  and  coagulates  the  albumin. 
The  temp&rature  should  be  from  115°  to  120°  F.  A  mixt- 
ure of  equal  parts  of  alcohol  and  water  stops  capillary 
oozing.  Paul  Carnot  has  recently  shown  that  a  solution 
of  gelatin  in  normal  salt  solution  (2  per  cent.)  will  arrest 
capillary  oozing  even  in  a  hemophiliac.  We  have  of  late 
employed  this  mixture  with  satisfactory  results  for  capillary 
oozing  from  an  incised  wound  in  a  victim  of  leukemia,  and 
for  the  arrest  of  epistaxis.  Carnot's  solution,  as  at  present 
used,  consists  of  5  parts  of  gelatin,  i  part  of  calcium  chlorid, 
and  100  parts  of  water,  and  the  mixture  is  sterilized  by 
heat. 

The  actual  cautery  is  a  very  ancient  hemostatic.  It  is 
still  used  in  some  cases  after  excising  the  upper  jaw,  in 
bleeding  after  the  removal  of  some  malignant  growths,  in 
continued  hemorrhage  from  the  prostatic  plexus  of  veins 
after  lateral  lithotomy,  and  to  stop  oozing  after  the  excision 
of  venereal  warts.  We  are  often  driven  to  its  use  in  "  bleeders  " 
— that  is,  those  persons  who  have  a  hemorrhagic  diathesis, 
and  who  may  die  from  having  a  tooth  pulled  or  from  receiv- 
ing a  scratch.  It  will  arrest  hemorrhage,  but  the  necrosed 
tissue  separates,  and  when  it  separates  secondary  hem^or- 
rhage  is  apt  to  set  in.  The  iron  for  hemostatic  purposes 
must  be  at  a  cherry  heat.  The  old-fashioned  iron,  which 
was  heated  in  a  charcoal  furnace,  is  rarely  used.     It  is  large, 


336   DISEASES  AND   INJURIES    OE  HEART  AND    VESSELS. 

clumsy,  and  cools  quickly  if  the  bleeding  is  profuse.  In  an 
emergency  we  may  heat  a  poker  or  a  coil  of  telegraph  wire. 
The  best  instrument  is  the  Paquelin  cautery.  The  Paquelin 
cautery  consists  of  an  alcohol  lamp,  a  metal  chamber  contain- 
ing benzene,  a  tube  of  entrance  for  air  containing  two  bulbs,  an 
exit  tube,  and  a  wooden-handled  cautery  instrument,  the  tip 
of  which  is  composed  of  spongy  platinum  (Fig.  92).  This 
can  be  kept  hot  even  when  bleeding  is  profuse.  If  the  iron 
is  very  hot,  it  will  not  stop  bleeding  completely.  In  order 
to  use  the  Paquelin  cautery,  light  the  lamp,  heat  the  cautery- 
tip  in  the  flame  until  it  becomes  red,  remove  it  from  the 
flame,  and  squeeze  the  bulb  repeatedly  until  the  tip  becomes 


Fig.  92. — Paquelin  cautery. 

bright  red.  Each  time  the  bulb  uncovered  with  netting  is 
squeezed  air  is  driven  through  the  metal  chamber  into  the 
tube  and  cautery,  and  this  air  carries  with  it  the  vapor  of 
benzene,  which  passes  to  the  hot  tip  and  takes  fire.  The 
degree  of  heat  maintained  depends  upon  the  rapidity  with 
which  the  bulb  is  squeezed. 

Skene  has  devised  a  method  known  as  electrohemostasis. 
He  grasps  the  vessel  or  tissue  with  specially  constructed  for- 
ceps, an  electric  current  generates  heat,  the  tissue  is  cooked 
and  the  walls  of  the  vessel  united.  A  heat  of  from  i8o°- 
190°  F.  is  required.  For  the  small  instrument  Skene  uses  a 
current  of  2  ma.  and  for  the  larger  instrument  a  current  of 
8  ma.^ 

Golden  Rules  for  Procedure  in  Pri77tary  Hemorrhage. —  i. 
In  arterial  hemorrhage  tie  the  artery  in  the  wound,  enlarging 
the  wound  if  necessary.  In  tying  the  main  artery  of  the 
1  A^ew  York  Medical  Journal,  February  iS,  1898. 


HEMORRHA  GE.  337 

limb  in  continuity  for  bleeding  from  a  point  below  we  fail  to 
cut  off  the  bleeding  from  the  distal  extremity,  and  hemor- 
rhage is  bound  to  recur.  If  we  do  not  look  into  the  wound, 
we  cannot  know  what  is  cut :  it  may  be  only  a  branch,  and 
not  a  main  trunk.  The  same  rule  obtains  in  secondar}-  hem- 
orrhage (Guthrie's  rule).^ 

2.  We  can  safely  ligate  veins  as  we  would  arteries. 

3.  In  a  wound  of  the  superficial  palmar  arch  tie  both  ends 
of  the  divided  vessel. 

4.  In  a  wound  of  the  deep  palmar  arch  enlarge  the 
wound,  if  necessaiy,  in  the  direction  of  the  flexor  tendons, 
at  the  same  time  maintaining  pressure  upon  the  brachial 
arten'.  Catch  the  ends  of  the  arch  with  hemostatic  forceps 
and  tie  both  ends.  If  the  arteiy  can  be  caught  by,  but  can- 
not be  tied  over  the  point  of,  the  forceps,  leave  the  instru- 
ment on  for  four  da}'S.  If  the  artery  cannot  be  caught  with 
forceps,  use  a  tenaculum.  The  ends  of  the  divided  vessel 
can  be  caught  and  must  be  caught  even  if  large  incisions  are 
needed  to  effect  it.  An  incision  which  will  probably  always 
expose  the  vessel  is  as  follows  :  i\Iake  a  cut  on  a  line  with 
the  injury  from  the  web  of  the  fingers  to  above  the  carpus 
separating  the  metacarpal  and  carpal  bones  until  the  artery 
is  reached.  (This  is  realh*  jMynter's  incision  for  excision  of 
the  wrist.)  In  former  days  if  the  surgeon  found  trouble  in 
grasping  the  ends  of  the  vessel,  he  applied  a  graduated  com- 
press. This  is  applied  as  follows  :  Insert  a  small  piece  of 
gauze  in  the  depths  of  the  wound,  put  over  this  a  larger 
piece,  and  keep  on  adding  bit  after  bit,  each  successive  piece 
larger  than  its  predecessor,  until  there  exists  a  conical  pad,  the 
apex  of  which  is  at  the  point  of  hemorrhage  and  the  base 
of  which  is  external  to  the  surface  of  the  palm.  Bandage 
each  finger  and  the  thumb,  put  a  piece  of  metal  over  the 
pad,  wrap  the  hand  in  gauze,  place  the  arm  upon  a  straight 
splint,  apply  firmly  an  ascending  spiral  reverse  bandage  of 
the  arm,  starting  as  a  figure-of-8  of  the  wrist,  and  hang  the 
hand  in  a  sling.  Instead  of  applying  a  splint,  we  may  place 
a  pad  in  front  of  the  elbow  and  flex  the  forearm  on  the  arm. 
The  palmar  pad  is  left  in  place  for  six  or  seven  days  unless 
bleeding  continues  or  recurs.  The  graduated  compress  is  an 
unreliable,  hence  a  dangerous,  method  of  treatment.  It  is 
an  evasion.  It  should  be  employed  at  the  present  time  only 
as  a  temporar}^  expedient,  until  ligatures  can  be  applied. 
The  old  rule  of  surgery  was  as  follows  :  If  bleeding  is  main- 
tained or  begins  again  after  application  of  a  graduated  com- 

'  For  .Murphy's  observations  on  anastomosis  of  vessels,  see  page  261. 
22 


338   DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

press,  ligate  the  radial  and  ulnar  arteries.  If  this  maneuver 
fails,  we  know  that  the  interosseous  artery  is  furnishing  the 
blood  and  that  the  brachial  must  be  tied  at  the  bend  of  the 
elbow.  If  this  fails,  amputate  the  hand.  At  the  present  day 
it  is  hard  to  conceive  of  such  radical  procedures  being  neces- 
sary for  hemorrhage. 

5.  In  primary  hemorrhage,  if  the  bleeding  ceases,  do  not 
disturb  the  parts  to  look  for  the  vessel.  If  the  vessel  is 
clearly  seen  in  the  wound,  tie  it ;  otherwise  do  not,  as  the 
bleeding  may  not  recur.  This  rule  does  not  hold  good 
when  a  large  artery  is  probably  cut,  when  the  subject  will 
require  transportation  (as  on  the  battle-field),  when  a  man 
has  dehrium  tremens,  mania,  or  delirium,  or  when  he  is  a 
heavy  drinker.  In  these  cases  always  look  for  an  artery  and 
tie  it. 

6.  When  a  person  is  bleeding  to  death  from  a  wound  of 
an  extremity,  arrest  hemorrhage  temporarily  by  digital 
pressure  in  the  wound  and  apply  above  the  wound  a  tourni- 
quet or  Esmarch  bandage.  Bring  about  reaction  and  then 
hgate,  but  do  not  operate  during  collapse  if  the  bleeding  can 
be  controlled  by  pressure. 


Fig.  93. — Application  of  lateral  ligature  to  a  vein 


7.  If  a  transverse  cut  incompletely  divides  an  artery,  it 
may  be  found  possible  to  suture  the  cut  if  it  does  not  include 
more  than  one-third  of  the  circumference  of  the  vessel. 
Longitudinal  cuts  can  be  sutured  (Murphy).  If  suturing  is 
impossible,  or  if  the  surgeon  prefers  not  to  attempt  it,  apply 
a  ligature  on  each  side  of  the  vessel-wound  and  then  sever 
the  artery  so  as  to  permit  of  complete  retraction. 

8.  If  a  branch  comes  off  just  below  the  ligature,  tie  the 
branch  as  well  as  the  main  trunk. 

9.  If  a  branch  of  an  artery  is  divided  very  close  to  a  main 
trunk,  tie  the  branch  and  also  the  main  trunk.  If  the  branch 
alone  be  tied,  the  internal  clot,  being  very  short,  will  be 
washed  away  by  the  blood-current  of  the  larger  vessel. 


HEMORRHAGE.  339 

10.  If  a  large  vein  is  slightly  torn,  put  a  lateral  ligature 
upon  its  wall  (Fig.  93).  Gather  the  rent  and  the  tissue  around 
it  in  a  forceps  and  tie  the  pursed-up  mass  of  vein-wall.  It  is 
a  wise  plan  to  pass  the  suture  through  the  two  outer  coats  by- 
means  of  a  needle  and  tie  the  knot  subsequently.  This  ex- 
pedient prevents  slipping.  If  a  longitudinal  wound  exists  in 
a  large  vein,  take  an  intestinal  needle  and  fine  silk  and  sew 
it  up  with  a  Lembert  suture. 

11.  When  a  branch  of  a  large  vein  is  torn  close  to  the 
main  trunk,  tie  the  branch,  and  not  the  main  trunk.  Apply 
practically  a  lateral  ligature. 

12.  If,  after  tying  the  cardial  extremity  of  a  cut  artery,  the 
distal  extremity  cannot  be  found,  even  after  enlarging  the 
wound  and  making  a  careful  search,  firmly  pack  the  wound. 

13.  In  bleeding  from  diploe  or  cancellous  bone,  use  Hors- 
ley's  antiseptic  wax,  or  break  in  bony  septa  with  a  chisel,  or 
plug  with  threads  of  gauze  or  scrapings  of  catgut. 

14.  In  bleeding  from  a  vessel  in  a  bony  canal,  plug  the 
canal  with  an  antiseptic  stick  and  break  the  wood,  or  fill  up 
the  orifice  of  the  canal  with  antiseptic  wax ;  or,  if  this  fails, 
ligate  the  artery  of  supply. 

15.  In  bleeding  from  the  internal  mammary  artery  the  old 
rule  was  to  pass  a  larged  curved  needle  holding  a  piece  of 
silk  into  the  chest,  under  the  vessel  and  out  again,  and  tie 
the  thread  tightly,  but  it  is  better  to  ligate  the  artery. 

16.  In  bleeding  from  an  intercostal  artery  make  pressure 
upward  and  outward,  or  throw  a  ligature  by  means  of  a 
curved  needle  entirely  over  a  rib,  tying  it  externally,  or, 
what  is  better,  resect  a  rib  and  tie  the  artery. 

17.  In  collapse  due  to  puncture  of  a  deep  vessel,  the  bleed- 
ing having  ceased,  do  not  hurry  reaction  by  stimulants.  Give 
the  clot  a  chance  to  hold.  Wrap  the  sufferer  in  hot  blankets. 
If  the  condition  is  dangerous,  however,  stimulate  to  save  life. 

18.  In  punctured  wounds,  as  a  rule,  try  pressure  before 
using  ligation. 

19.  After  a  severe  hemorrhage  always  put  the  patient  to 
bed  and  elevate  the  damaged  part  (if  it  be  an  extremity  or 
the  head). 

20.  A  clot  which  holds  for  twelve  hours  after  a  primary 
hemorrhage  will  probably  hold  permanently ;  but  even  after 
twelve  hours  be  watchful  and  insist  on  rest. 

21.  If  recurrence  of  a  hemorrhage  from  a  limb  is  feared, 
mark  with  anilin  or  iodin  the  spot  on  the  main  artery  where 
compression  is  to  be  applied,  apply  a  tourniquet  loosely,  and 
order  the  nurse  to  screw  it  up  and  to  send  for  the  physician 


340   DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

at  the  first  sign  of  renewed  bleeding.     This  must  often  be 
done  in  gunshot-wounds. 

22.  When  the  femoral  vein  is  divided  high  up  the  advice 
commonly  given  is  to  ligate  the  vein  and  also  the  femoral 
artery.  Braune  taught  that  because  of  the  venous  valves 
there  is  no  collateral  circulation,  and  to  tie  the  vein  alone 
renders  gangrene  inevitable.  Niebergall  shows  that  the 
valves  may  be  overcome  by  moderate  arterial  pressure,  and 
thus  collateral  circulation  be  established.  Hence,  when  the 
femoral  vein  is  divided  tie  the  vein,  but  leave  the  artery  un- 
tied, so  as  to  furnish  the  necessary  pressure.^ 

23.  In  extradural  hemorrhage  trephine.  The  side  to  be 
trephined  is  determined  by  the  symptoms,  and  not  by  the 
situation  of  the  injury.  The  opening  is  made  on  a  level  with 
the  upper  orbital  border  and  one  and  a  quarter  inches  be- 
hind the  external  angular  process.  This  opening  exposes 
the  middle  meningeal  and  its  anterior  branch  (Keen).  If  this 
does  not  expose  a  clot,  trephine  over  the  posterior  branch, 
on  the  same  level  and  just  below  the  parietal  eminence. 
When  the  clot  is  found  enlarge  the  opening  with  the  ron- 
geur, scoop  out  the  clot,  and  arrest  the  bleeding  by  passing 
catgut  ligatures  on  each  side  of  the  injury  in  the  vessel 
through  the  dura,  under  the  artery  and  out  again,  and  then 
tying  them.  If  the  artery  lies  in  a  bony  canal,  plug  the  canal 
with  Horsley's  wax.  In  subdural  hemorrhage  open  the  dura 
and  endeavor  to  ligate.  If  this  procedure  is  impossible,  pack 
with  one  piece  of  iodoform  gauze, 

24.  In  hemorrhage  from  a  cerebral  sinus  catch  the  edges 
of  the  opening  with  forceps,  if  possible,  and  apply  a  lateral 
ligature,  or  leave  the  forceps  in  place  for  forty-eight  hours 
or  compress  firmly  with  one  large  piece  of  iodoform  gauze. 

25.  In  extramedullary  spinal  hemorrhage  rapidly  advanc- 
ing and  threatening  life  perform  a  laminectomy  and  arrest 
the  hemorrhage. 

26.  In  bleeding  from  a  tooth-socket  use  chlorid-of-ethyl 
spray  or  ice.  If  this  treatment  fails,  plug  with  gauze  infil- 
trated with  tannin  or  soaked  in  antipyrin  solution  of  a  strengh 
of  10  per  cent.,  or  in  Carnot's  solution  of  gelatin,  close  the 
jaws  upon  the  plug,  and  hold  them  with  Barton's  bandage. 
If  this  expedient  fails,  soak  the  plug  in  Monsel's  solution, 
or  plug  with  a  bit  of  cork,  and  if  this  is  futile,  use  the  cautery. 
Pressure  on  the  carotid  and  ice  over  the  jaw  and  neck  are 
indicated.  It  may  be  necessary  to  tie  the  external  carotid 
artery. 

1  Niebergall,  Deut.  Zeit.f.  Chir.,  vol.  xxxvii.,  Nos.  3  and  4. 


HEMORRHAGE.  34 1 

27.  In  intra-abdominal  hemorrhage  open  the  belly.  In 
intra-abdominal  hemorrhage  it  is  necessary  to  operate  dur- 
ing shock.  If  the  blood  accumulates  so  rapidly  as  to  prevent 
the  location  of  the  bleeding  point,  compress  the  aorta  or  pack 
the  abdominal  cavity  with  large  sponges.  In  seeking  for  the 
bleeding  point  remove  the  sponges  one  by  one,  or  have  the 
pressure  momentarily  relaxed  from  time  to  time.  In  paren- 
chymatous hemorrhage  try  packing  with  iodoform  gauze. 
In  the  liver,  if  this  fails,  suture  the  torn  edge  or  use  the  cau- 
tery. Severe  wounds  of  the  spleen  demand  splenectomy. 
Wounds  of  the  kidney  may  be  sutured,  but  may  require  par- 
tial or  complete  nephrectomy.  Mesenteric  vessels  are  ligated 
en  masse  with  silk  (Senn).  Wounds  of  the  stomach  and  intes- 
tines causing  hemorrhage  require  stitching  of  their  edges. 
When  there  are  an  infinite  number  of  points  of  bleeding  take 
a  number  of  sponges,  tie  a  piece  of  tape  firmly  to  each  one, 
pack  many  places  in  the  belly  with  the  sponges,  bring  the 
tapes  out  of  the  wound,  and  remove  the  sponges  from  below 
upward  one  at  a  time,  securing  the  bleeding  points  as  they 
come  into  view. 

28.  In  abdominal  section  for  disease  of  the  female  pelvic 
organs  bleeding  is  limited  by  the  clamp  or  by  pressure-for- 
ceps. Ligation  en  masse  is  often  practised.  Use  silk.  A 
large  mass  can  be  transfixed  and  tied  in  sections.  Bleeding 
edges  are  stitched.  Areas  of  oozing  are  treated  with  tem- 
porary pressure  and  hot  water,  or,  if  this  fails,  by  the  cautery. 
Packing  can  be  used  as  a  tamponade,  which  is  a  gauze  pouch, 
pieces  of  gauze  being  packed  into  this  pouch  after  its  inser- 
tion into  the  belly. 

29.  A  ruptured  varicose  vein  requires  a  compress,  a  band- 
age from  the  periphery  up,  and  elevation. 

30.  Most  cases  of  capillary  bleeding  can  be  controlled 
by  compression  with  gauze  pads  soaked  in  water  at  a  tem- 
perature of  115°  to  120°  F.  This  contracts  the  vessels 
and  seals  them  with  coagulated  albumin.  Keetly  in  1878 
impressed  the  profession  with  the  value  of  hot  water  as  a 
styptic.  Centuries  ago  surgeons  used  hot  oil  for  the  same 
purpose.  Capillary  bleeding  can  often  be  controlled  by  the 
application  of  gauze  soaked  in  Carnot's  solution.  Carnot's 
original  solution  was  gelatin  in  normal  salt  solution,  2  parts  of 
gelatin  to  100  parts  of  salt  solution.  He  now  uses  5  parts  of 
gelatin,  i  part  of  chlorid  of  calcium,  and  100  parts  of  water 
sterilized  by  heat.  A  2  per  cent,  solution  of  suprarenal  extract 
may  control  capillary  oozing.  If  other  means  fail  to  control 
capillary  hemorrhage,  the  cautery  must  be  used.     Understand 


342   DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

that  the  term  capillary  bleeding  does  not  so  much  mean 
bleeding  from  genuine  capillaries  as  it  does  bleeding  from 
arterioles  and  venules. 

31.  Pressure  above  a  wound  arrests  arterial  hemorrhage, 
but  aggravates  venous  bleeding.  Pressure  below  a  wound 
arrests  venous  hemorrhage,  but  increases  arterial  bleeding. 
Remember  these  facts  when  applying  pressure. 

32.  A  moderate  epistaxis  may  be  arrested  by  an  injection 
of  peroxid  of  hydrogen,  an  injection  of  a  solution  of  antipyrin, 
or  an  injection  of  Carnot's  solution  of  salt  and  gelatin.  Favor- 
ite domestic  expedients  are  keeping  the  arms  raised  above  the 
head  and  applying  ice  to  the  back  of  the  neck.     In  severe 


Fig.  94. — Plugging  the  nares  for  epistaxis  (Guerin). 

epistaxis,  or  bleeding  from  the  nose,  examine  the  nose  by 
means  of  a  head-mirror  and  a  speculum.  If  a  little  point  of 
ulceration  is  found,  touch  it  with  a  hot  iron.  If  the  bleeding 
is  a  general  ooze,  if  it  is  high  up,  or  if  the  cautery  does  not 
arrest  it,  pack  the  nares.  It  may  be  necessary  to  pack  one 
nostril  or  both.  Pass  a  Bellocq  cannula  (Fig.  94)  along  the 
floor  of  one  nostril  into  the  pharynx,  project  the  stem  into 
the  mouth,  tie  a  plug  of  lint  or  gauze  wet  with  Carnot's  so- 
lution of  salt  and  gelatin  to  the  stem,  and  withdraw  it.  Hold 
the  double  string  which  emerges  from  the  nostril  in  the  hand 
and  pack  gauze  wet  with  gelatin  solution  from  before  back- 
ward.  Tie  the  strings  together  over  the  plug ;  if  both  nostrils 


HEMORRHAGE.  343 

are  plug^ged,  the  strings  from  one  nostril  are  fastened  to  the 
strings  from  the  other.  Do  not  use  subsulphate  of  iron,  as 
it  forms  a  disgusting,  clotty,  adherent  mass.  If  a  Bellocq 
cannula  is  not  obtainable,  push  a  soft  catheter  into  the  phar- 
ynx, catch  it  with  a  finger,  pull  it  forward,  and  tie  the  plug  to 
it.  Remove  the  plug  in  two  or  three  days.  Do  not  leave 
it  longer.  It  blocks  up  decomposing  fluids  and  may  lead  to 
blood-poisoning.  Pick  out  the  front  plug  first,  hold  the  string 
of  the  second  plug  in  the  hand,  push  the  plug  back  into  the 
pharynx,  catch  it  with  forceps,  and  withdraw  plug  and  string 
through  the  mouth. 

33.  In  gunshot-wounds  the  primary  hemorrhage  is  slight 
unless  a  large  vessel  is  cut.  The  bleeding  may  be  visible  or 
may  be  internal  (concealed),  the  blood  running  into  a  natu- 
ral cavity  or  among  the  muscles.  Capillary  oozing  is  arrested 
by  very  hot  water  and  compression.  Venous  bleeding  is 
usually  arrested  by  compression.  If  a  large  vessel  is  the 
source  of  bleeding,  enlarge  the  wound  and  tie  the  vessel. 
If  the  artery  cannot  be  found  in  the  wound,  tie  the  main 
trunk. 

34.  In  prolonged  bleeding  from  a  leech-bite  try  compres- 
sion over  a  plug  saturated  with  alum  or  with  tannin.  If  this 
fails,  pass  under  the  wound  a  harelip-pin  and  encircle  it 
with  a  piece  of  silk.  If  this  fails,  use  the  actual  cautery  or 
excise  the  bite  and  suture  the  incision. 

35.  In  severe  bleeding  from  the  ear  elevate  the  head,  put 
an  ice-bag  over  the  mastoid,  give  opium  and  acetate  of  lead, 
and,  if  blood  runs  into  the  mouth,  plug  the  Eustachian  tube 
with  a  piece  of  catheter. 

36.  Umbilical  hemorrhage  in  infants  requires  pressure 
over  a  plug  containing  tannin,  alum,  or  gelatin  solution.  If 
compression  fails,  pass  harelip-pins  under  the  navel  and  apply 
a  twisted  suture.      If  this  fails,  use  the  actual  cautery, 

37.  Rectal  bleeding  requires  elevation  of  the  buttocks, 
insertion  of  plugs  of  ice,  ice  to  the  anus  and  perineum, 
astringent  injections  (alum),  and  the  internal  use  of  opium 
and  acetate  of  lead.  If  these  means  fail,  plug  the  bowel 
over  a  catheter,  or  insert  and  inflate  a  Paterson  bag  or  a 
colpeurynter,  or  tampon  and  use  a  T-bandage.  If  the  bleed- 
ing persists  or  if  a  considerable  vessel  is  bleeding,  stretch 
the  sphincter,  catch  the  bowel  and  draw  it  down,  seize  the 
vessel,  and  tie  it  if  possible ;  if  not,  leave  the  forceps  in  place. 
Failing  in  this,  the  actual  cautery  m^ust  be  used. 

38.  Subcutaneous  hemorrhage,  if  severe  and  continuing, 
demands  that  an  incision  be  made  and  ligatures  be  applied. 


344   DISEASES  AND   INJURIES    OE  HEART  AND    VESSELS. 

39.  Bleeding  from  a  cut  urethral  meatus  requires  the 
insertion  of  styptic  cotton  and  the  application  of  pressure. 
Moderate  bleeding  from  the  urethra  can  usually  be  arrested 
by  a  very  warm  bougie,  by  very  warm  injections,  or  by 
tying  a  condom  over  a  catheter,  and,  after  inserting  it,  in- 
flating the  condom  by  blowing  through  the  catheter  and 
plugging  the  orifice  of  the  instrument,  thus  using  pressure. 
Sitting  with  the  perineum  on  a  thickly  folded  towel  is 
useful.  Ice  to  the  perineum  does  good.  The  patient  can 
lie  down,  have  a  folded  towel  applied  to  the  perineum, 
and  a  crutch-handle  pushed  upon  the  towel,  the  lower  end 
of  the  crutch  being  jammed  against  the  foot  of  the  bed. 
If  a  solid  bougie  has  been  first  introduced,  firm  pressure 
can  be  made  by  this  method.  If  these  means  are  futile, 
perform  an  external  urethrotomy  and  reach  the  bleeding 
point. 

40.  Hemorrhage  from  the  prostate  requires  hot  injections, 
the  introduction  of  a  large  bougie  first  dipped  in  very  warm 
water,  and  the  retention  of  a  catheter  for  two  days.  Perineal 
section  may  be  required,  or  suprapubic  cystotomy  with 
packing  which  does  not  occlude  the  ureteral  orifices. 

41.  Vesical  hemorrhage  usually  ceases  spontaneously,  in 
which  case  the  urine  must  be  drawn  off  and  the  viscus  be 
washed  out  frequently  with  a  solution  of  boric  acid,  to  pre- 
vent septic  cystitis.  If  blood-clots  prevent  the  flow  of  urine, 
break  them  up  with  a  catheter  or  a  lithotrite  and  inject  vin- 
egar and  water,  a  2  per  cent,  solution  of  carbolic  acid,  or  a 
solution  of  bicarbonate  of  sodium.  Perfect  quiet  is  to  be 
maintained,  cold  acid  drinks  to  be  given,  ice-bags  to  be  put 
to  the  perineum  and  hypogastric  region,  and  opium  with 
acetate  of  lead,  or  gallic  acid  to  be  given  by  the  mouth.  If 
the  hemorrhage  is  severe  or  persistent,  perform  a  suprapubic 
cystotomy,  wash  out  the  bladder,  and,  if  necessary,  plug  the 
bladder  with  gauze,  leaving  the  ureters  uncovered. 

42.  In  hemorrhage  after  lateral  Hthotomy,  ligate  if  pos- 
sible. If  the  vessel  can  be  caught  but  cannot  be  ligated, 
leave  the  forceps  in  place.  If  we  cannot  catch  the  vessel 
with  forceps,  use  a  tenaculum.  If  the  tenaculum  fails,  pass 
a  threaded  curved  needle  through  the  tissues  around  the 
vessel  and  tie  the  ligature.  Plugs  of  ice  and  injections  of 
hot  water  may  be  tried.  These  means  failing,  pressure  is 
indicated.  Take  a  cannula,  fasten  to  it  a  chemise  (Fig.  95), 
empty  clots  from  the  bladder,  insert  the  instrument  into  the 
viscus,  and  pack  gauze  between  the  sides  of  the  cannula 
and  the  chemise.     The  chemise  is  bulged  out  and  pressure 


HEMORRHAGE. 


345 


is  made.     Tie  the  cannula  by  means  of  tapes  to  a  T-bandage. 
Pressure  is  thus  combined  with  \-esical  drainage.     Buckstone 
Brown  makes  pressure  by  inflating  a  rubber  bag  with  air. 
The    hot    iron    may    occasionally  be 
demanded. 

43.  Renal  bleeding  requires  ice  to 
the  loin,  tannic  acid  and  opium,  gallic 
acid  or  sulphuric  acid  internally,  and 
perfect  quiet.  If  the  bleeding  threat- 
ens life  and  the  diseased  organ  is  iden- 
tified, make  a  lumbar  incision,  and 
suture  or  perform  nephrectomy ;  if 
not  sure  which  organ  is  diseased, 
perform  an  abdominal  nephrectomy. 
The  use  of  a  cystoscope  will  show 
from  which  ureter  blood  is  emerging. 

44.  Vaginal  hemorrhage  requires 
the    ligature   or   the  tampon. 

45.  Severe  uterine  hemorrhage 
(unconnected  with  pregnancy)  re- 
quires the  tampon.  Persistent  hem- 
orrhage due  to  morbid  growths  may 
require  removal  of  the  tubes  and 
appendages,  ligation  of  the  uterine 
and  ovarian  arteries,  or  hysterectomy. 

46.  Hematemesis,  or  bleeding  from  the  stomach,  is  treated 
by  the  swallowing  of  ice,  giving  tannic  acid  (dose,  20  or  30 
grains)  or  IMonsei's  solution  (3  drops).  Never  give  tannic 
acid  and  Monsel's  solution  at  the  same  time,  as  they  mix 
and  form  ink.  Opium  is  usually  ordered.  Acetate  of  lead 
and  opium  and  gallic  acid  are  favorite  remedies,  and  ergot 
is  used  by  many.  Give  no  food  by  the  stomach.  If  life  is 
threatened  by  bleeding  from  an  ulcer,  open  the  belly  and 
excise  the  ulcer  and  suture  the  wound.  If  severe  hemor- 
rhage follows  injury,  make  an  exploratory^  laparotomy. 
Always  remember  that  furious  and  even  fatal  gastro-intes- 
tinal  hemorrhage  may  be  due  to  cirrhosis  of  the  liver.  A 
slight  injury  may  be  the  exciting  cause  of  such  a  hemor- 
rhage.    In   this   condition,  of  course,  operation  is  useless. 

47.  In  bleeding  from  the  small  bowel  give  acetate  of  lead 
and  opium,  sulphuric  acid,  or  Monsel's  salt  in  pill  form 
(3  grains),  allow  no  food  for  a  time,  and  insist  on  liquid  diet 
for  a  considerable  period.  If  hemorrhage  threatens  life,  do 
a  celiotomy  and  find  the  cause.  If  ulcer  exists,  excise  it  and 
suture,  or  suture  a  perforation  without  previously  excising. 


Fig.  95. — Cannula  a  chemise. 


346  DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

If  violent  hemorrhage  follows  injury,  explore  to  discover  the 
cause. 

48.  In  bleeding  from  the  large  bowel,  use  styptic  injections 
(10  grains  of  alum  or  5  grains  of  bluestone  to  oj  of  water). 
If  bleeding  is  low  down,  use  small  amounts  of  the  solution  ; 
if  high  up,  large  amounts.  Do  not  use  absorbable  poisons. 
In  dangerous  cases  perform  an  exploratory  operation  to  find 
the  cause.     (For  rectal  bleeding  see  37,  p.  343.) 

49.  Hemoptysis,  or  bleeding  from  the  lung,  is  treated  by 
morphin  hypodermatically,  by  perfect  rest,  by  dry  cups  or 
ice  over  the  affected  spot  if  it  can  be  located,  and  by  the 
administration  of  gallic  acid,  which  drug  aids  coagulation.^ 
Of  late  nitrite  of  amyl  by  inhalation  has  given  good  results. 

50.  In  hemorrhage  from  wound  of  the  lung  do  not  open 
the  chest  unless  life  is  threatened.  If  life  is  endangered, 
resect  a  rib,  allow  the  lung  to  collapse,  and  see  if  this  arrests  . 
bleeding.  If  bleeding  still  continues,  remove  several  ribs, 
find  the  bleeding  point,  ligate  or  employ  forcipressure.  A 
small  cavity  may  be  packed  wath  gauze.  If  a  large  surface 
is  bleeding,  fill  the  pleural  sac  with  gauze  and  pack  more 
gauze  against  the  oozing  surface.^ 

Reactionary  or  Recurrent  Hemorrhage  (called  also 
Consecutive,  Intermediate,  or  Intercurrent). — This  form  of 
hemorrhage  comes  on  during  reaction  from  an  accident  or 
an  operation — that  is,  during  the  first  forty-eight  hours,  but 
usually  within  twelve  hours.  It  is  bleeding  from  a  vessel  or 
vessels  which  did  not  bleed  during  the  shock  which  accom- 
panied operation,  and  which  vessels  were  overlooked  and  not 
tied.  It  may  be  due  to  faultily  applied  ligatures.  It  is  fa- 
vored by  vascular  excitement  or  hypetrophied  heart.  The 
bleeding  is  rarely  sudden  and  severe,  but  is  usually  a  gradual 
drop  or  trickle.  The  Esmarch  apparatus  is  not  unusually 
the  cause.  The  constricting  band  paralyzes  the  smaller 
arteries,  which  do  not  bleed  during  shock  and  do  not  con- 
tract as  shock  departs ;  hence  bleeding  comes  on  w^ith  reac- 
tion. To  lessen  the  danger  of  the  Esmarch  apparatus  use 
a  broad  constricting  band  rather  than  a  rubber  tube.  After 
an  amputation,  when  the  larger  vessels  have  been  tied,  gauze 
pads  wet  with  hot  water  (115°  to  120°  F.)  should  be  placed 
between  the  flaps.     This  not  only  arrests  capillary  oozing, 

^  The  use  of  ergot  is  a  general  but  questionable  practice.  Bartholow  and 
others  hold  that  this  drug  does  harm  ;  it  contracts  all  the  arterioles,  and  hence 
more  blood  flows  from  an  area  where  there  is  damage.  Purgatives  do  good  in 
bleeding  from  the  lung  by  taking  blood  to  the  abdomen  and  lowering  blood- 
pressure. 

^  See  author's  case,  Annals  of  Surgery^  Jan.,  1898. 


SECOXDARY  HEMORRHAGE.  347 

but  Stimulates  vessels  and  shows  points  of  bleeding  which 
were  not  previously  visible,  and  these  points  are  ligated. 
During  reaction  after  an  amputation,  if  slight  hemorrhage 
occurs,  elevate  the  stump  and  compress  the  flaps.  If  the 
hemorrhage  persists  or  at  any  time  becomes  severe,  make 
pressure  on  the  main  artery  of  the  limb,  open  the  flaps, 
turn  out  the  clots,  find  the  bleeding  point,  ligate,  asepticize, 
close,  drain,  and  dress.  In  any  severe  reactionary  hemor- 
rhage open  the  wound  at  once  and  ligate. 

Secondary  liemorrhag"e  may  occur  at  any  time  in  the 
period  between  forty-eight  hours  after  the  accident  or  opera- 
tion and  the  complete  cicatrization  of  the  wound.  Secondary 
hemorrhage  may  be  due  to  atheroma,  to  slipping  of  a  liga- 
ture, to  inclusion  of  nerve,  fascia,  or  muscle  in  the  ligature, 
to  sloughing,  to  erysipelas,  to  septicemia,  to  pyemia,  to  gan- 
grene, and  to  overaction  of  the  heart.  The  great  majority 
of  cases  of  secondary  hemorrhage  are  due  to  infection,  and 
the  application  of  modern  surgical  principles  has  rendered 
secondarv^  bleeding  a  rare  calamity.  If  during  an  operation 
the  vessels  are  found  atheromatous,  a  thread  should  be 
passed,  by  means  of  a  Hagedorn  needle,  around  the  vessel, 
including  a  cushion  of  tissue  in  the  loop  of  the  ligature  (this 
prevents  cutting  through,  Fig.  85).  Acupressure  may  be 
used  in  such  a  case.  If  the  surgeon  decides  to  employ  the 
ligature,  he  must  not  tie  tightly,  but  must  endeavor  to  approx- 
imate the  coats  rather  than  to  cut  them.  Two  ligatures 
can  be  applied  or  the  stay-knot  may  be  used.  One  great 
trouble  with  atheromatous  arteries  is  that  their  coats  cannot 
contract ;  another  trouble  is  that  the  Hgature  cuts  entirely 
through  them.  If  after  an  operation  the  pulse  is  found  to  be 
forcible,  rapid,  and  jerking,  give  aconite,  opium,  and  low  diet. 
The  bleeding  may  come  on  suddenly  and  furiously,  but  is 
usually  preceded  by  a  bloody  stain  in  wound-fluids  which 
had  become  free  from  blood. 

Treatment  of  Secondary  Hemorrhage. — Supposing  a 
case  of  leg-amputation  in  which,  several  days  after  the  opera- 
tion, a  little  oozing  is  detected,  the  treatment  is  to  elevate 
the  stump,  apply  two  compresses  ov^er  the  flaps,  and 
cany  a  firm  bandage  up  the  leg.  If  the  bleeding  is  profuse 
or  becomes  so,  make  pressure  on  the  main  artery,  open  and 
tear  the  flaps  apart  with  the  fingers,  find  the  bleeding  vessel 
and  tie  it,  turn  out  the  clots,  asepticize,  close,  drain,  and  dress. 
If  the  bleeding  begins  at  a  period  when  the  stump  is  nearly 
healed,  cut  down  on  the  main  arten,- just  above  the  stump 
and  ligate.     In  secondar}-  hemorrhage  from  a  blood-vessel 


348   DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

in  nodular  tissue,  apply  a  suture-ligature  or  tie  higher  up, 
or,  if  this  fails,  amputate.  When  secondary  hemorrhage 
arises  in  a  sloughing  wound  apply  a  tourniquet  or  an 
Esmarch  bandage,  tear  the  wound  open  to  the  bottom  with 
a  grooved  director,  look  for  the  orifice  of  the  vessel,  dissect 
the  artery  up  until  a  healthy  point  is  reached,  cut  it  across, 
and  tie  both  ends.  If  this  fails,  apply  a  suture-ligature  or 
use  acupressure.  In  secondary  hemorrhage  from  atherom- 
atous vessels,  use  the  suture-ligature,  double  Hgature  with 
a  stay  knot,  or  employ  acupressure. 

Secondary  hemorrhage  may  occur  after  ligation  in  conti- 
nuity, the  blood  usually  coming  from  the  distal  side.  If  the 
dressings  are  slightly  stained  with  blood,  put  on  a  graduated 
compress.  If  the  bleeding  continues  or  is  severe,  make 
pressure  on  the  main  artery  of  the  limb,  open  the  wound  and 
ligate,  wrap  the  part  in  cotton,  elevate,  and  surround  with  hot 
bottles.  If  this  religation  is  done  on  the  femoral  and  fails, 
do  not  ligate  higher  up,  as  gangrene  will  certainly  occur,  but 
amputate  at  once,  above  the  point  of  hemorrhage.  If  dealing 
with  the  brachial  artery,  do  not  amputate,  but  ligate  higher 
up  and  make  compression  in  the  wound.  In  a  secondary 
hemorrhage  from  the  innominate,  tie  the  innominate  again 
and  also  tie  the  vertebral. 

2,  Operations  on  the  Vascular  System. 

Paracentesis  auriculi,  or  tapping  the  heart-cavity,  has 
been  suggested  for  the  relief  of  an  over-distended  heart  from 
pulmonary  congestion.  The  right  auricle  can  be  tapped. 
Push  the  aspirator-needle  directly  backward  at  the  right  edge 
of  the  sternum,  in  the  third  interspace.  This  operation  is  not 
recommended,  as  it  is  highly  dangerous  and  is  of  question- 
able value. 

Paracentesis  pericardii,  or  tapping  the  pericardial  sac, 
is  only  done  when  life  is  endangered  by  effusion.  Introduce 
the  needle  two  inches  to  the  left  of  the  left  edge  of  the  ster- 
num, in  the  fifth  interspace,  and  push  it  directly  backward 
(thus  avoiding  the  internal  mammary  artery). 

Operation  for  Pericardial  Bffusion  or  Suppuration. 
— The  operation  of  tapping  should  be  abandoned  in  favor 
of  a  safer  but  more  radical  procedure.  There  is  no  spot 
where  we  can  introduce  the  needle  with  perfect  safety,  and 
the  heart  or  pleura  may  be  wounded  ;  further,  as  Brentano 
shows,^  tapping  will  not    completely  empty  the  sac.     In    a 

^  Deiitsch.  med.   Woch.,  Feb.  Ii,  1890. 


OPE  RATI  ox  FOR    VARIX   OF  LEG.  349 

purulent  case  tapping  gives  practically  no  chance  of  cure. 
No  general  anesthetic  should  be  used.  A  portion  of  the 
fifth^'rib  or  the  cartilage  on  the  fifth  rib  should  be  excised, 
the  pericardium  exposed  and  punctured  in  order  to  deter- 
mine the  nature  of  the  fluid  present.  If  the  fluid  is  serous,  it 
can  be  drained  away  through  a  small  incision,  and  the  peri- 
cardium may  either  be  sutured  or  drained  with  gauze.  If 
the  fluid  be  purulent,  the  pericardium  should  be  stitched  to  the 
chest-wall  and  opened.  Clots  should  be  removed  by  irri- 
gation with  hot  salt  solution  and  a  drainage-tube  should  be 
introduced. 

Operation  for  Varix  of  I,eg.— Many  cases  do  not  re- 
quire operation.  In  some,  operation  is  positively  harmful. 
In  some  selected  cases  it  is  ver}'  useful  to  remove  certain 
complications  (ulcer,  ezcema,  etc.),  and  to  relieve  the  patient 
from  annoyance,  but  the  operation  rarely  absolutely  cures 
the  condition.  The  indications  and  contraindications  are  dis- 
cussed on  p.  307.  Never  operate  if  phlebitis  exists,  except 
to  treat  thrombosis. 

Trendelenburg's  Operation. — I  have  employed  this  with 
much  satisfaction  in  cases  of  varix  of  the  leg  following 
involvement  of  the  saphenous  in  the  thigh.  Trendelen- 
burg believes  that  in  varix  the  \-alves  in  the  saphenous 
become  incompetent  because  of  high  central  pressure.  The 
veins  of  the  leg  distend,  as  they  are  unable  to  support  such  a 
long  column  of  blood,  and  finally  the  blood  begins  to  flow 
in  the  wrong  direction  in  the  saphenous,  a  "  vicious  circle  " 
being  established. 

Make  an  incision  about  four  inches  long  over  the  internal 
saphenous  vein  at  the  junction  of  the  lower  and  middle 
thirds  of  the  thigh.  Expose  the  vein,  ligate  each  visible 
branch,  ligate  the  saphenous  at  the  lower  end  of  the  wound 
and  also  at  the  upper  end,  and  remove  the  portion  of  vein 
included  between  the  Hgatures.  By  this  operation  the  central 
pressure  is  intercepted  and  the  dilated  veins  in  consequence 
shrink.  Some  surgeons  have  advised  the  removal  of  the  en- 
tire length  of  the  long  saphenous  vein. 

Madehing  cuts  down  over  the  \-arices  and  ligates  at 
various  points.  Schede  makes  a  circular  cut  (a  circumcision) 
completelv  around  the  leg  at  the  junction  of  the  upper 
and  middle  thirds,  the  incision  reaching  to  the  deep  fascia. 
All  bleeding  points  are  ligated  and  the  edges  of  the 
incision  are  stitched  together.  Fcrgusson  ties  the  saph- 
enous vein  near  the  femoral  and  removes  a  section  from 
it.      This    makes    the    varices     clearly    evident.      A    semi- 


350   DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

lunar  incision  is  made  to  surround  the  varices,  which 
incision  reaches  to  the  deep  fascia.  The  flap  is  raised  and 
dissected  up,  the  vessels  are  tied,  and  the  flap  is  sutured  in 
place.  The  author  of  this  operation  claims  that  it  is  most 
satisfactory  and  certain.  Phelps  advises  multiple  ligation, 
which  may  be  described  as  follows :  At  several  points 
over  the  long  saphenous  vein  make  skin  incisions  in  the 
long  axis  of  the  vessel.  Each  incision  is  two  inches  long. 
At  each  point  apply  two  ligatures  one  inch  apart  and  remove 
the  portion  of  vein  between  them. 

Open  Operation  for  Varicocele. — The  open  operation 
is  by  far  the  best  procedure  for  varicocele.  The  instruments 
used  are  a  scalpel,  an  aneurysm-needle,  curved  needles,  a 
grooved  director,  a  dissecting-forceps,  AUis's  dry  dissector, 
hemostatic  forceps,  and  scissors. 

Operation. — The  patient  is  placed  in  a  recumbent  position. 
He  may  be  given  a  general  anesthetic  or  Schleich's  fluid 
may  be  injected.  The  operator  stands  on  the  diseased  side. 
The  assistant  stands  on  the  sound  side  and  makes  pressure 
over  the  inguinal  ring  of  the  affected  side.  A  fold  of  skin 
is  pinched  up  on  the  scrotum,  and  the  surgeon  transfixes  it 
in  the  line  of  the  cord,  so  that  he  will  have  an  incision 
about  one  and  a  half  inches  long  running  downward  from 
below  the  external  ring.  The  skin  and  fascia  are  cut  with 
a  scalpel,  the  veins  are  well  exposed  by  means  of  an  Allis 
dissector,  and  the  cord  is  located  and  held  aside.  A  double 
ligature  of  strong  catgut  or  chromicized  gut  is  passed  under 
the  veins  by  an  aneurysm-needle.  The  threads  are  sepa- 
rated one  inch,  tied  tightly,  and  the  ends  are  left  long.  The 
veins  between  the  ligatures  are  excised.  The  two  gut  liga- 
ures  are  tied  together  and  cut.  This  shortens  the  cord.  The 
scrotum  is  sewed  up  with  silkworm-gut,  a  small  drainage- 
tube  being  used  for  twenty-four  hours.  Healing  is  complete 
in  one  week. 

Bloodgood,  of  Johns  Hopkins  Hospital,  points  out  that  it 
is  well  to  avoid  dividing  the  genital  branch  of  the  genito- 
crural  nerve  which  supplies  the  cremaster  muscle.  If  this  nerve 
should  be  divided,  the  cremaster  will  become  lax  and  return 
of  the  varicocele  will  be  favored.  Bloodgood  makes  the  in- 
cision over  the  external  ring,  draws  the  veins  up  and  resects 
them.  A  wound  so  placed  heals  more  certainly  and  promptly 
than  does  a  wound  of  the  scrotum. 

Subcutaneous  I/igature  for  Varicocele. — In  this 
operation  employ  every  antiseptic  precaution.  The  patient 
stands,  and  the  operator,  sitting  in  front  of  him,  holds  the 


PHLEBOTOMY,    OR    VENESECTION. 


351 


veins  in  a  fold  of  skin  away  from  the  vas  deferens  by  means 
of  the  thumb  and  index-finger  of  the  left  hand.  A  large 
straight  needle  carrying  a  double  piece  of  strong  silk  is 
passed  entirely  through  the  scrotum,  between  the  veins  and 
the  vas.  The  needle  is  again  inserted  at  the  puncture  from 
which  it  emerged,  is  carried  around  under  the  skin  and  in 
front  of  the  veins,  and  emerges  at  its  original  point  of  entry. 
The  veins  are  thus  surrounded  by  the  silk.  The  patient, 
who  now  lies  down,  is  placed  under  the  first  stage  of  ether, 
and  the  double  Hgatures  are  separated  as  far  as  possible 
from  each  other,  tied,  and  cut  off,  the  knots  slipping  in 
through  the  puncture.  This  operation  presents  certain  dan- 
gers. The  veins  may  be  wounded  and  the  vas  or  other 
structures  may  be  included.  In  an  operation  it  is  always 
best  to  be  able  to  see  what  we  are  doing;  and  the  open 
operation,  being  safe,  is  preferred  to  the  subcutaneous. 

Phlebotomy,  or  Venesection. — The  instrument  used 
in  \"enesection  is  a  lancet  or  bistoury.  A  fillet  or  tape,  an 
antiseptic  pad,  and  a  bandage  are  required.  A  stick  should 
be  at  hand  for  the  patient  to  grasp. 

Operation. — The  patient  sits  on  a  chair  "with  the  arm 
abducted,  extended,  and  inclined  outward"  (Barker).  The 
parts  are  asepticized  and  a  tape  is  tied  around  the  arm  just 
above  the  elbow.  The  surgeon  stands  to  the  right  of  the 
arm,  holds  the  elbow  with  his  left  hand,  and  puts  his  thumb 
upon  the  vein  below  the  intended  point  of  puncture.  The 
patient  grasps  a  stick 
firmly  and  works  his  fin- 
gers to  swell  the  veins. 
Either  the  median  ce- 
phalic or  the  median 
basilic  may  be  opened 
(Figs.  96.  97).  The  me- 
dian basilic  is  the  more 
distinct,  and  is  the  vein 
usually  selected.  In 
opening  it  do  not  go 
too  deep,  as  nothing  but 
the  bicipital  fascia  sepa- 
rates it  from  the  brachial 
artery.  The  median  ce- 
phalic may  be  selected  (we  thus  avoid  endangering  the 
brachial  artery) ;  under  this  vein  lies  the  external  cutaneous 
ner\'e  (Fig.  96).  Steady  the  vein  with  the  thumb  and  open 
it  by  transfixion,  making  an  oblique  cut  which   divides   two- 


FiG   q6 — ^upei  tiLial  \  eins       Fig.  97. — Incisions  for 

in  front  ol  elbcn  .  venesection. 

(Bernard  and  Huette.) 


352   DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

thirds  of  it.  Remove  the  thumb  and  allow  bleeding  to  go 
on,  instructing  the  patient  to  work  his  fingers.  When  faint- 
ness  begins  remove  the  fillet,  put  an  antiseptic  pad  over  the 
puncture,  apply  a  spiral  reversed  bandage  of  the  hand  and 
arm  and  a  figure-of-8  bandage  of  the  elbow,  and  place  the 
arm  in  a  sling  for  several  days. 

Transfusion  of  Blood. — This  operation  has  been  a 
recognized  procedure  since  1824,  though  it  has  been  known 
since  1492,  when  transfusion  was  employed  in  the  case  of 
Pope  Innocent  VIII.  Its  chief  use  was  in  severe  hem- 
orrhage, especially  post  partum,  in  w^hich  it  served  to  replace 
the  blood  lost  and  supplied  something  for  the  heart  to  con- 
tract upon  until  new  blood  formed.  Senn  insists  that  the 
operation  has  proved  an  absolute  failure.  It  does  not  pre- 
vent death  from  hemorrhage,  and  the  transferred  blood- 
elements  do  not  retain  vitality.  Von  Bergmann  showed 
that  after  severe  hemorrhage  we  do  not  need  to  inject  nutri- 
tive elements,  but  do  need  to  restore  the  greatly  diminished 
intracardiac  and  intravascular  pressure.  At  the  present  day 
a  saline  fluid  is  infused  in  preference  to  transfusing  blood. 
In  fact,  the  operation  of  transfusion  has  become  all  but 
extinct.  It  exposes  the  patient  to  the  danger  of  embolism 
and  infection,  its  employment  requires  material  and  instru- 
ments often  difficult  to  obtain  in  an  emergency,  and  it  has 
no  single  element  of  value  beyond  that  secured  by  the  use 
of  salt  solution. 

Intravenous  infusion  of  saline  fluid  is  used  after  severe 
hemorrhage,  in  shock,  in  diabetic  coma,  in  post-operative 
suppression  of  urine,  and  occasionally  in  sepsis.  After  a 
hemorrhage  its  beneficial  effects  are  often  prompt  and  obvious. 
This  saline  fluid  increases  the  arterial  tension,  gives  the 
heart  enough  matter  to  contract  upon,  and  so  restores  the 
activity  of  the  circulation,  and  does  not  destroy  the  red  cor- 
puscles as  plain  water  would  do.  We  may  use  a  simple 
apparatus  consisting  of  a  rubber  tube,  a  funnel,  and  an  aspi- 
rating-needle.  Some  employ  an  Aveling  syringe,  and  others 
Collins's  apparatus  (Fig.  gS).  The  last-named  instrument 
can  be  used  without  any  danger  of  air  entering  with  the 
fluids.  Spencer's  instrument  (Fig.  99)  is  convenient  and  use- 
ful. Normal  salt  solution  is  the  fluid  usually  employed, 
of  a  strength  of  0.6  per  cent,  (a  heaping  teaspoonful  of 
common  salt  to  a  quart  of  warm  boiled  water).  Some  sur- 
geons employ  an  artificial  serum  which  contains  50  grains 
of  chlorid  of  sodium,  3  grains  of  chlorid  of  potassium,  25 
grains  of  sulphate  and  25  grains  of  carbonate  of  sodium,  and 


TRANSFUSION  OF  BLOOD. 


353 


2  grains  of  phosphate  of  sodium  in  a  quart  of  boiled  water. 
Szumann's  solution  consists  of  6  parts  of  common  salt,  i 
part  of  sodium  carbonate,  and  looo  parts  of  water.  The 
following  solution  is  used  by  Locke  and  Hare :  calcium 
chlorid,  25  gm.;  potassium  chlorid,  i  gm.;  sodium  chlorid, 
9  gm. ;  sterile  water  sufficient  to  make  i  liter.  One  bottle 
of  the  commercial  fluid  when  diluted  to  i  liter  gives  a  solu- 
tion of  the  above  composition.  The  results  from  artificial 
serum  containing  many  elements  are  no  better  than  from 


Fig.  98. — Intravenous  injection  of  saline  fluid. 


normal  salt  solution.  Whatever  fluid  is  used,  it  should  be 
at  a  temperature  of  105°  F.  or  over  as  it  enters  the  vein. 
The  stimulant  effect  of  the  heat  is  of  great  value.  The  fluid 
must  not  be  allowed  to  cool;  and  a  nurse  gives  constant 
attention  to  the  temperature  of  the  fluid  in  the  reservoir. 
This  degree  of  heat  will  not  damage  the  corpuscles  ;  in  fact, 
Dawbarn  has  used  saline  fluid  at  a  temperature  of  ii8°F. 
without  doing  damage  to  corpuscles  and  with  great  benefit  to 
the  patient.  From  |  pint  to  2  pints  or  even  more  are  slowly 
injected,  the  condition  of  the  patient  determining  the  amount 
given.  In  one  case  of  violent  hemorrhage  the  author  used 
over  2  quarts.  In  order  to  infuse  this  fluid,  tie  a  fillet  well  above 
the  elbow,  and  expose  by  dissection  the  median  basilic  vein, 
or  the  basilic  vein  in  the  portion  of  its  course  where  it  is 
superficial  to  the  deep  fascia.  Tie  the  vein.  Incise  it  above 
the  ligature,  insert  a  fine  cannula,  and  hold  the  cannula 
firmly  in  the  lumen  by  tightening  a  second  ligature  (Fig.  98). 
Remove  the  fillet.  Slowly  and  gradually  introduce  the  fluid,. 
23 


354   DISEASES  AND   INJURIES   OE  HEART  AND    VESSELS. 

carefully  watching  the  pulse.  Occupy  at  least  ten  minutes  in 
introducing  a  pint,  except  in  a  very  desperate  case  of  hemor- 
rhage, when  it  may  be  given  more  rapidly.  When  the  ten- 
sion of  the  pulse  returns  withdraw  the  cannula,  tie  the  second 
ligature  tightly,  sew  up  the  wound,  and  dress  it  aseptically. 


Fig.  99. — Spencer's  apparatus  for  the  infusion  of  saline  fluid  into  a  vein.     The  cannula  can 
be  plunged  directly  into  the  vessel  without  preliminary  incision. 

In  very  severe  operations  an  assistant  should  conduct  the 
infusion  while  the  surgeon  is  operating.  It  may  be  neces- 
sary to  repeat  the  operation  if  the  circulation  fails  again. 
The  infusion  of  a  very  large  amount  of  saline  fluid  may  do 
harm.  It  may  embarrass  the  heart  and  may  lead  to  edema 
of  the  lungs  or  brain. 

Arterial  Transfusion  and  Infusion  of  Saline  Fluid  in 
Arteries. — Hueter  preferred  the  arterial  method  of  transfu- 
sion, in  order  to  send  the  blood  more  gradually  to  the  heart, 
and  thus  prevent  sudden  disturbance  of  the  circulation.  A 
little  air  in  an  artery  will  do  no  harm,  and  the  danger  of 
venous  embolism  is  avoided.  Saline  fluid  can  be  infused 
into  an  artery.  The  radial  artery  is  exposed  and  surrounded 
by  three  ligatures,  and  the  thread  toward  the  heart  is  at  once 
tied.  The  distal  ligature  is  slightly  tightened  to  cut  off 
anastomotic  blood-supply.  The  artery  is  cut  transversely 
half  through;  the  syringe  is  inserted,  pointed  toward  the 
periphery,  and  fastened  by  the  third  ligature;  the  second 
ligature  is  loosened  and  the  blood  is  injected.  On  finishing, 
the  peripheral  thread  is  tied  tightly  and  that  portion  of  the 
artery  which  held  the  cannula  is  excised.  Dawbarn  puts  a 
hypodermatic  needle  into  the  radial  artery  and  injects  saline 
fluid. 


HEMOPHILIA,    OR   HEMORRHAGIC  DIATHESIS.        355 

Hemophilia,  or  Hemorrhagic  Diathesis.— The  teini 
hemophilia  expresses  the  existence  in  an  individual  of  a  ten- 
dency to  profuse  or  even  uncontrollable  hemorrhage  spon- 
taneously or  as  a  result  of  some  ver}-  trivial  injury. 

Hemorrhage  may  take  place  from  mucous  or  serous  mem- 
branes or  from  wounds  of  the  cutaneous  surface,  into  tissue, 
into  organs,  under  the  scalp,  or  into  the  external  genitals.  In 
a  hemophiliac,  if  a  cut  is  made,  the  hemorrhage  from  the 
larger  vessels  is  easily  arrested,  but  capillar}^  oozing  continues. 

The  condition  is  far  more  common  in  males  than  in 
females,  and  if  it  exists  in  a  female,  which  it  rarely  does,  it 
is  not  usually  provocative  of  dangerous  hemorrhage.  The 
disease  is  transmitted  by  heredity.  It  is  transmitted  by  a 
mother,  who  is  usually  free  from  the  disease,  but  whose 
father  had  it,  to  a  son,  and  the  son  bleeds  dangerously  from 
slight  causes.  The  existence  of  the  tendency  is  rarely  sus- 
pected until  the  first  dentition,  and  possibly  not  till  puberty; 
"  70  per  cent,  of  cases  appear  before  the  fifth  year."  ^  The 
discovery  of  the  existence  of  such  a  condition  may  not  be 
made  until  a  tooth  is  pulled,  and  extraction  is  followed  by 
persistent  bleeding.  It  is  alleged  that  the  tendency  may  dis- 
appear in  middle  life. 

The  cause  of  the  condition  is  unknown.  It  has  been 
assumed  that  there  is  a  condition  of  the  blood  which  pre- 
vents coagulation,  but  the  blood  of  a  hemophiliac  coagulates 
outside  of  the  body  as  well  as  any  other  blood.  Further- 
more, Agnew  had  a  case  in  which  hemophilia  was  limited  to 
the  head  and  neck,  and  there  have  been  cases  in  which  the 
bleeding  occurred  from  one  kidney.  Some  maintain  that 
there  is^tructural  defect  in  the  capillaries.  In  a  case  in  the 
Jefferson  Medical  College  Hospital  in  which  it  was  abso- 
lutely necessan,^  to  amputate  a  finger  because  of  a  crush,  a 
careful  study  of  the  vessels  of  the  finger  by  Dr.  Coplin 
failed  to  show-  any  disease  of  the  blood-vessels.  A  surgeon 
must  be  on  the  lookout  forthis  condition,  and  should  inquire 
for  it  before  deciding  to  do  an  operation.  If  it  exists,  only 
an  operation  of  imperative  necessity  should  be  undertaken. 

A  child  who  is  "  a  bleeder  "  must  be  unceasingly  watched 
and  guarded.  A  tendency  to  profuse  oozing  exists  in  leu- 
kemia because  of  the  condition  of  the  blood,  but  this  is  not 
hemophiha.  A  tendency  to  oozing  also  exists  during  jaun- 
dice. 

Treatment. — The  oozing  is  difficult  and  often  mipossible 
to  control.     The  internal  administration   of  such   drugs   as 

1  R.  C.  Cabot,  in  International  Text-book  of  Surgery. 


356   DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

ergot,  gallic  acid,  and  acetate  of  lead  is  useless.  It  is  claimed 
that  chlorid  of  calcium  internally  is  of  service.  The  local 
use  of  astringents  is  of  no  avail.  Prolonged  elevation  may 
in  rare  cases  succeed.  In  the  case  in  the  Jefferson  Medical 
College  Hospital  the  bleeding  was  arrested,  after  numerous 
expedients  failed,  by  compression  and  hot  water.  Nurses 
sat  by  the  bed  for  several  days,  constantly  compressed  the 
wound  with  gauze  pads  soaked  in  hot  water,  and  changed 
the  pads  as  soon  as  they  cooled.  The  local  use  of  Carnot's 
solution  of  gelatin  has  saved  several  cases  from  death.  It 
has  been  advised  to  take  some  blood  from  a  healthy  man 
and  put  it  in  the  cut,  in  the  hope  that  a  firm  clot  will  form. 


3.  Ligation  of  Arteries  in  Continuity. 

The  instruinents  used  in  this  operation  are  two  scalpels 
(one    small,   one    medium),   two    dissecting-forceps,    several 


Fig.  100. — Aneurysm-needle  of  Saviard. 

hemostatic  forceps,  toothed  forceps,  blunt  hooks  or  broad 
metal  retractors,  an  Allis  dissector,  an  aneurysm-needle,  for 
superficial  arteries  the  instrument  of  Saviard  (Fig.  100),  for 

deep  vessels  the  needle  of  Dupuy-' 
tren  (Fig.  10 1),  ligatures  of  cat- 
gut, of  chromicized  gut,  or  of  silk, 
curved  needles  and  a  needle- 
holder,  sutures  of  silkAvorm-gut, 
and  the  reflector  or  electric  fore- 
head-lamp for  deep  vessels. 

The  position  in  which  the 
patient  is  placed  varies  according 
to  the  vessel  to  be  ligated,  though 
the  body  is  supine  except  when 
ligation  is  to  be  performed  on  the 
gluteal,  sciatic,  or  popliteal  artery. 
The  operator,  as  a  rule,  stands 
upon  the  affected  side,  cutting 
from  above  downward  on  the 
right  side  and  from  below  upward  on  the  left  side. 

Operation. — Accurately  determine  the  line  of  the  artery, 


Fig.  ioi. — Dupuytren's  aneurysm- 
needles. 


LIGATION  OF  ARTERIES.  357 

and  make  an  incision  at  a  slight  angle  to  this  line,  avoid- 
ing subcutaneous  veins,  and  holding  the  scalpel  like  a  fiddle- 
bow  or  a  dinner-knife  while  cutting  the  superficial  parts, 
and  like  a  pen  while  incising  the  deeper  parts.  On  reaching 
the  deep  fascia  make  out  the  required  muscular  gap  by  the 
eye  and^  finger,  so  moving  the  extremity  as  to  bring  indi- 
vidual muscles  into  action.  Treves  cautions  us  not  to 
depend  upon  the  yellow  line  of  fat,  which  often  cannot  be 
seen  in  emaciated  people  or  when  an  Esmarch  bandage  is 
employed ;  nor  upon  the  white  line  due  to  attachment  to  the 
fascia  of  an  intermuscular  septum.  In  opening  the  deep 
portion  of  the  wound  relax  the  bounding  muscles  by  altering 
the  posture.  Open  a  muscular  interspace  with  a  sharp  knife, 
not  with  a  dissector.  I\Iake  the  depths  of  the  wound  as  long 
as  the  superficial  incision.  Do  not  tear  structures  apart 
with  a  grooved  director ;  cut  them.  Arrest  hemorrhage  as 
it  occurs.  Try  to  find  the  situation  of  the  arteiy  with  the 
finger.  Pulsation  is  present,  but  it  may  be  very  feeble  and 
hard  to  detect.  The  artery  feels  like  a  ver}^  thin  rubber 
tube ;  it  is  compressible,  though  not  so  easily  as  a  vein, 
and  when  compressed  feels  like  a  flat  band  which  is  thinner 
in  the  center  than  at  the  edges  (Treves).  A  nerve  feels  like 
a  hard  round  cord.  The  veins  are  soft,  larger  than  their 
related  arteries,  and  so  very  compressible  that  they  can 
scarcely  be  felt  when  pressed  upon,  and  compression  causes 
distal  distention.  If  the  wound  can  be  seen  into  clearly,  it  will 
be  noted,  as  Treves  asserts,  that  "the  nerves  stand  out  as 
clear,  rounded,  white  cords ;  that  the  veins  are  of  a  purple 
color  and  of  somewhat  uneven  and  wa\y  contour ;  that  the 
artery  is  regular  in  outline  and  of  a  pale-pink  or  pinkish- 
yellow  tint,  the  large  vessels  being  of  lighter  color  than  the 
small."  All  the  arteries  of  the  upper  extremity  and  all  the 
arteries  below  the  knee  are  accompanied  by  two  veins,  known 
as  "venae  comites."  The  arteries  of  the  head  and  neck, 
except  the  lingual,  have  each  a  single  attending  vein;  the 
lingual  has  vense  comites.  JMost  of  the  smaller  arteries  of 
the  trunk  (pudic,  internal  mammary,  etc.)  have  venae  comites. 
These  companion  veins  may  lie  on  each  side  of  the  artery  or 
in  front  and  back  of  it,  and  they  communicate  with  one  another 
by  transverse  branches  crossing  the  arter)-.  On  reaching 
the  sheath  pick  up  this  structure  with  toothed  forceps  so 
as  to  make  a  transverse  fold,  and  thus  avoid  catching  the 
artery  or  vein  ;  lift  the  fold  to  see  that  it  is  free,  and  open 
the  sheath  by  cutting  toward  the.  edge  of  the  forceps  with  a 
scalpel  held  obliquely  with  its  back  toward  the  vessel,  thus 


358    DISEASES   AND   INJURIES    OF  HEART  AND    VESSELS. 


making  a  small  longitudinal  incision  (PI.  2,  Figs,  i,  2).  Hold 
the  edge  of  the  incised  sheath  with  the  forceps ;  pass  a 
metal  dissector  under  the  vessel  and  from  the  forceps ;  this 
clears  one-half  of  the  vessel.  Grasp  the  other  edge  of  the 
sheath  and  pass  the  blunt  dissector  all  the  way  around  the 
vessel.  Pass  an  aneurysm-needle  under  the  cleared  vessel, 
away  from  the  forceps  holding  the  sheath  and  away  from  the 
vessel's  most  dangerous  neighbor.  Thread  the  needle  and  with- 
draw it.  If  venae  comites  are  in  the  way,  try  to  separate  them ; 
but  if  this  proves  difficult,  include  them  in  the  ligature.  In  small 
vessels  always  include  them  if  they  are  in  the  way,  as  this 
saves  trouble.  If,  in  passing  the  needle,  a  large  vein  is  severely 
wounded  (such  as  the  femoral),  Jacobson  advises  the  em- 
ployment of  digital  pressure  in  the  lower  portion  of  the 
wound  while  the  artery  is  being  tied  on  a  level  above  or 
below  that  of  the  vein-injury,  and  after  ligation  the  main- 
tenance of  pressure  on  the  wound  for  a  couple  of  days.  A 
slight  puncture  in  a  vein  merely  requires  a  lateral  ligature. 
A  small  longitudinal  cut  can  be  closed  with  Lembert  sutures 
of  fine  silk.  After  getting  a  ligature  under  an  artery  press 
for  a  moment  upon  the  artery  over  the  ligature,  which  is 
held  taut ;  this  pressure  will  arrest  pulsation  below  if  the 
ligature  is  around  the  main  artery  and  there  is  not  a  double 
vessel.  Tie  the  thread  at  right  angles  to  the  vessel  with  a 
reef-knot  (Fig.  102),  rupturing  the  internal  and  middle  coats. 
As  the  ligature  is  tightened  place  the  extended  index-fingers 
along  the  ligature  up  to  the  artery  (PI.  2, 
Fig.  3),  using  the  middle  joints  as  the  ful- 
crum of  a  lever  by  placing  them  against 
each  other. 

Ballance  and  Edmunds  have  recently 
claimed,  as  Scarpa  and  Sir  Philip  Cramp- 
ton  did  long  since,  that  it  is  not  neces- 


FiG.  102. — Reef-knot. 


Fig.  103. — Diagram  showing  the 
action  of  the  ligature. 


sary  to  divide  the  internal  and  middle  coats  to  insure  oblit- 
eration. If  this  claim  be  true,  the  danger  of  secondary 
hemorrhage  can  be   greatly  lessened.       Holmes,    however, 


LIGATIONS. 


Plate  2. 


..  Opening  the  Sheath  for  Ligation  of  an  Artery  (Guerin).  2.  Sheath  of  Arterj'  Open  (Guerin). 
3.  Tightening  the  Knot  in  Ligation  (Guerin).  4.  Anatomy  of  the  Iliac  Arteries,  and  showing  the 
lines  of  incision  for  their  ligation  :  i,  Abernethy's  incision  (Guerin).  5,  6.  Ballance  and  Ed 
mund's  Stay-knots. 


RADIAL   ARTERY.  359 

thinks  the  older  method  the  more  certain  of  the  two.  Bal- 
lance  and  Edmunds  use  floss  silk  as  a  ligature-material, 
because  it  is  soft,  broad,  and  flat,  and  they  surround  the 
artery  with  a  double  ligature.  Ballance  and  Edmunds  thus 
describe  the  application  of  the  stay-knot:  "the  best  way 
of  tying  two  ligatures  is  to  make  on  each  separately,  and  in 
the  same  way,  the  first  hitch  of  a  reef-knot,  and  to  tighten 
each  separately  so  that  the  loop  lies  in  contact  with  the  ves- 
sel without  constricting  it.  Then  taking  the  ends  on  one 
side  together  in  one  hand  and  the  two  ends  on  the  other 
side  in  the  other  hand,  constrict  the  vessel  sufficiently  to 
occlude  it,  and  finally  complete  the  reef-knot.  The  sim- 
plest way  of  completing  the  knot  is  to  treat  the  two  ends  in 
each  hand  as  a  single  thread  and  to  tie  as  if  completing  a 
single  reef-knot."  This  knot  is  shown  in  PI.  2,  Figs.  5 , 6.  The 
stay-knot  applied  by  this  method  is  of  great  value  if  a  vessel 
be  atheromatous. 

The  chief  dangers  after  ligation  are  secondary  hemor- 
rhage and  gangrene.  Rigid  asepsis  usually  prevents  the 
first ;  rest,  elevation,  and  heat  antagonize  the  second. 

Radial  Artery. — The  line  of  the  radial  artery  is  from 
the  middle  of  the  front  of  the  elbow-joint  to  the  ulnar  side 
of  the  styloid  process  of  the  radius.  The  li)ic  in  the  tab- 
atiere  is  from  the  apex  of  the  styloid  process  to  the  posterior 
angle  of  the  first  interosseous  space. 

Anatomy  (PL  3,  Fig.  5). — The  radial  arter}^  though  smaller 
than  the  ulnar,  is  the  direct  continuation  of  the  brachial. 
It  arises  from  the  bifurcation  of  the  brachial  half  an  inch 
below  the  bend  of  the  elbow,  runs  down  the  radial  side  of 
the  forearm  to  the  front  of  the  styloid  process  of  the  radius, 
passes  beneath  the  extensor  muscles  of  the  first  metacarpal 
bone  and  of  the  first  phalanx  of  the  thumb,  and  over  the 
carpus  to  the  first  interosseous  space.  It  is  crossed  by  the 
tendon  of  the  extensor  secundi  internodii  pollicis,  enters  into 
the  palm  between  the  heads  of  the  first  dorsal  interosseous 
muscle,  and  forms  the  deep  palmar  arch.  The  arter}'  in  the 
upper  two-thirds  of  its  course  is  somewhat  overlaid  by  the 
supinator  longus  muscle  ;  in  the  lower  one-third  of  the  fore- 
arm it  is  superficial.  In  the  upper  third  of  the  forearm  it 
lies  between  the  supinator  longus  on  the  outside  and  the 
pronator  radii  teres  on  the  inside ;  in  the  lower  two-thirds 
of  the  forearm  it  lies  between  the  supinator  longus  on  the 
outside  and  the  flexor  carpi  radialis  on  the  inside.  Two 
venae  comites  attend  the  vessel.  The  radial  ner\'e  is  to  the 
outer,  or  radial,  side  of  the  artery,  well  removed  from  the 


360  DISEASES  AND  INJURIES   OF  HEART  AND    VESSELS. 

artery  in  the  upper  third,  nearer  to  the  artery  in  the  middle 
third,  far  external  to  the  artery  in  the  lower  third,  the  nerve 
at  this  point  passing  beneath  the  supinator  longus  muscle. 
The  radial  artery,  from  above  downward,  rests  upon  the 
biceps  tendon,  the  supinator  brevis,  the  flexor  sublimis,  the 
pronator  radii  teres,  the  flexor  longus  pollicis,  the  pronator 
quadratus  muscles,  and  the  radius.  The  best  guide  to  the 
radial  artery  in  the  forearm  is  the  outer  edge  of  the  flexor 
carpi  radialis  muscle  or  the  inner  edge  of  the  supinator 
longus  muscle. 

The  tabatiere  anatomique  of  Cloquet,  or  the  anatomical 
snuff-box,  is  a  triangle  whose  base  is  the  lower  edge  of  the 
posterior  annular  ligament,  the  ulnar  side  being  formed  by 
the  extensor  secundi  internodii  pollicis  tendon,  the  radial 
side  by  the  extensor  ossis  metacarpi  and  the  extensor  primi 
internodii  pollicis  tendons ;  the  floor  consists  of  the  trape- 
zium, scaphoid,  their  dorsal  ligaments,  and  the  base  of  the 
first  metacarpal  bone. 

Operations. — Ligation  in  the  tabatiere  is  a  dissecting-room 
operation  of  but  little  practical  use.  The  patient  is  placed 
in  a  recumbent  position,  the  arm  is  abducted,  and  the  forearm 
is  placed  midway  between  pronation  and  supination  (Barker). 
The  surgeon  stands  upon  the  side  operated  upon.  An  in- 
cision two  inches  in  length  is  made  along  the  radial  border 
of  the  extensor  secundi  internodii  pollicis  muscle.  The  skin 
and  superficial  fascia  are  cut  and  some  venous  branches  are 
divided.  The  deep  fascia  is  incised  and  the  vessel  is  easily 
found  and  tied  before  it  passes  between  the  heads  of  the 
first  dorsal  interosseus  muscle  (Barker). 

Ligation  of  the  Lozver  Third. — In  this  operation  (PI.  3, 
Fig.  6)  the  patient  is  placed  supine,  the  arm  is  abducted,  the 
forearm  is  supinated,  is  rested  upon  a  table,  and  is  held  by  an 
assistant.  The  surgeon  stands  on  the  side  operated  upon, 
and  cuts  from  above  downw^ard  on  the  right  forearm  and  from 
below  upward  on  the  left  forearm.  The  line  of  the  vessel 
should  be  determined,  and  may  be  indicated  with  iodin  or 
anilin.  An  incision  one  and  a  half  inches  long  is  made  at  a 
slight  angle  to  this  line  and  midway  between  the  supinator 
longus  and  the  flexor  carpi  radialis  muscles,  which  incision 
must  not  extend  below  the  level  of  the  tuberosity  of  the 
scaphoid  bone.  In  the  superficial  fascia  watch  for  the  super- 
ficial radial  vein,  and  if  it  comes  into  view  push  it  aside. 
Incise  the  superficial  fascia  and  locate  each  guide-tendon. 
Open  the  deep  fascia  in  the  length  of  the  first  cut ;  try  to 
separate    the    veins,  but    if  they    strongly    adhere    include 


LIGATIONS. 


Plate 


ULNAR   ARTERY.  3-61 

them  in  the  hgature.  There  is  no  special  fascial  sheath. 
The  radial  nerve  will  not  be  seen,  but  a  division  of  the 
anterior  cutaneous  nerve  is  frequently  found  in  relation  with 
the  vessel.  The  needle  can  be  passed  in  either  direction.  A 
high  origin  of  the  superficialis  vol^  arteiy  is  confusing. 

Ligation  of  the  Middle  TJiird. — In  this  operation  the  posi- 
tion of  the  patient  should  be  the  same  as  in  the  preceding. 
A  two-inch  incision  is  made.  Veins  of  the  subcutaneous 
tissues  are  avoided.  Lying  upon  the  deep  fascia  is  the 
anterior  division  of  the  musculocutaneous  nerve.  Open 
the  fascia :  find  the  inner  edge  of  the  supinator  longus  mus- 
cle and  draw  it  outward,  flexing  the  elbow  partly  if  neces- 
sary. Be  sure  not  to  cut  external  to  this  muscle.  Find  the 
vessel  where  it  is  bound  down  by  connective  tissue  to  the 
pronator  radii  teres  muscle,  separate  the  veins,  and  pass  the 
ligature  from  without  inward.     The  nerve  is  external. 

Ligation  of  the  Upper  Third  (PL  3,  Fig.  6). — In  this  opera- 
tion the  incision  is  as  described  above,  only  higher  up.  The 
artery  is  between  the  supinator  longus  and  the  pronator 
radii  teres,  which  muscles  are  at  once  differentiated  by  the 
different  direction  of  their  fibers.  The  arter}^"  is  usually  cov- 
ered by  the  supinator  longus  muscle,  which  must  be  retracted 
externally.  The  ner\^e  is  not  seen.  The  ligature  may  be 
passed  in  either  direction. 

Ulnar  Artery. — No  one  lijie  will  overlie  the  entire  ulnar 
artery.  The  line  of  the  upper  third  runs  from  the  middle  of 
the  front  of  the  elbow-joint  to  the  point  of  junction  of  the 
upper  and  middle  thirds  of  the  ulna.  The  line  of  the  lower 
two-thirds  runs  from  the  tip  of  the  internal  condyle  of  the 
humerus  to  the  radial  side  of  the  pisiform  bone  (PI.  3,  Figs. 
5,6). 

Anatomy  (PI.  3,  Fig.  5). — The  ulnar  arteiy  arises  from 
the  brachial  bifurcation  and  runs  obliquely  inward  under  the 
median  nerve  and  a  group  of  muscles  from  the  internal  con- 
dyle ;  it  turns  down  the  arm,  being  covered  in  the  middle 
third  of  its  course  by  the  flexor  carpi  ulnaris  muscle.  In  the 
lower  third  it  is  superficial,  between  the  tendons  of  the  flexor 
carpi  ulnaris  on  the  inside  and  the  flexor  sublimis  digitorum 
on  the  outside,  the  vessel  being  a  little  overlapped  by  the 
flexor  carpi  ulnaris.  This  vessel  rests  first  upon  the  brachi- 
alis  anticus  muscle,  next  upon  the  flexor  profundus,  to  which 
it  is  bound  by  a  distinct  process  of  fascia,  and  next  upon  the 
annular  Hgament,  which  structure  it  crosses  to  become  the 
superficial  palmar  arch.  Two  vense  comites  attend  the  vessel. 
In  the  upper  third  the  nerve  is  well  internal,  but  in  the  lower 


362    DISEASES  AND   INJURIES    OF  HEART  AND    VESSELS. 

two-thirds  the  nerve  hes  near  the  artery  and  to  its  ulnar  side. 
The  guide  is  the  outer  edge  of  the  flexor  carpi  ulnaris. 

Operations  (PI.  3,  Fig.  6). — Ligation  of  the  Lower  Third. 
— The  position  in  this  operation  is  the  same  as  for  hgation 
of  the  radial  artery.  Make  a  two-inch  incision  to  the  radial 
side  of  the  tendon  of  the  flexor  carpi  ulnaris,  which  incision 
should  not  be  taken  lower  than  a  point  one  inch  above  the 
pisiform  bone.  Avoid  the  superficial  ulnar  vein  in  the  subcu- 
taneous tissue.  Open  the  deep  fascia,  find  the  tendon  of  the 
flexor  carpi  ulnaris,  flex  the  wrist  and  draw  the  tendon 
inward,  open  a  second  layer  of  fascia,  clear  the  vessel,  separate 
the  veins,  and  pass  the  ligature  from  within  outward  to  avoid 
the  nerve.  On  the  artery  is  the  palmar  cutaneous  branch  of 
the  ulnar  nerve,  and  this  branch  must  not  be  included  in  the 
ligature. 

Ligation  of  the  Middle  Third  (PI.  3,  Fig.  6). — In  this  opera- 
tion the  position  is  the  same  as  in  the  preceding  one,  the  in- 
cision being  three  inches  long.  Avoid  the  anterior  ulnar  vein 
and  the  branches  of  the  internal  cutaneous  nerve  in  the  super- 
ficial fascia.  Open  the  deep  fascia  a  little  external  to  the 
superficial  cut  (Treves).  Find  the  space  between  the  flexor 
carpi  ulnaris  and  the  superficial  flexor,  feeling  with  the  index- 
finger,  and  when  the  space  is  discovered  flex  the  wrist,  re- 
tract the  flexor  carpi  ulnaris  inward  and  the  flexor  sublimis 
digitorum  outward,  open  the  fascia,  find  the  ulnar  nerve,  look 
external  to  it  for  the  artery,  clear  the  vessel,  separate  the 
venae  comites,  and  pass  the  needle  from  within  outward.  The 
ulnar  artery  should  not  be  ligated  in  continuity  in  the  upper 
third  of  its  course. 

Bracllial  Artery. — The  line  of  the  brachial  artery  is  from 
the  junction  of  the  anterior  and  middle  thirds  of  the  outlet 
of  the  axilla,  the  arm  being  abducted  and  the  forearm  supi- 
nated,  to  the  middle  of  the  front  of  the  elbow-joint. 

Anatomy  (PI.  3,  Fig.  1). — The  brachial  artery  is  the  pro- 
longation of  the  axillary,  and  extends  from  the  lower  edge  of 
the  teres  major  muscle  to  half  an  inch  below  the  bend  of  the 
elbow,  where  it  divides  into  the  radial  and  ulnar  arteries.  It 
lies  first  to  the  inner  side  of  the  arm,  but  passes  to  the  front 
of  the  elbow.  It  is  crossed  by  no  muscle,  and  is,  in  fact, 
superficial,  barring  its  being  somewhat  overlaid  in  part  of 
its  course  by  the  edge  of  the  biceps  muscle.  The  median 
nerve  is  external  above,  crosses  over  the  vessel  about  the 
middle  of  the  arm,  and  reaches  the  inner  side  of  the  artery. 
The  coracobrachialis  and  biceps  muscles  are  external,  and 
both  often  overlap  the  vessel.     The   ulnar  nerve  is  internal 


BRACHIAL   ARTERY.  3^3 

above  and    the    median  nerve  is  internal  below  the  middle. 
The  basilic  vein  is  to  the  inner  side  of  the  artery,  being  out- 
side the  deep  fascia  to  near  the  middle  of  the  arm  at  which 
point  it  pierces  it.     The  artery  above  is  separated  from  the 
loner  head  of  the  triceps  by  the  musculospiral  nerve  and 
superior  profunda  artery  and  vein  ;  it  rests  trom  above  down 
on  the  inner  head  of  the  triceps,  the  coracobrachiahs   and 
the  brachialis    anticus    muscles.     The  arteiy  is  covered  by 
skin  by  superficial  fascia,  and  by  deep  fascia.     The  intemal 
cutaneous  ner^■e  lies  in  front  of  the  arter>^  upon  the  deep 
fascia,  until  it  pierces  the  fascia  along  with  the  basque  vein 
The  artery  has  vens  comites,  and  m  its  upper  half  has  also 
the  basihc  vein  to  its  inner  side.     The  guide  to  the  brachial 
is  the    inner  edge  of  the  biceps  muscle.     Just  m  front  o 
the  elbow-joint  the  artery  lies  in  a  triangle,  the  base  of  which 
is  formed  bv  an  ^imaginary  transverse  line  above  the  con- 
dvles  and  the  apex  by  the  junction  of  the  pronator  radu 
teres 'and  the  supinator  longus    muscles.     The    outer    line 
is  the  supinator  longus,  the  mner   line  is  the  pronator  radu 
teres  and  the  floor  is  formed  by  the  brachialis   anticus   and 
the   supinator  bre^ds    muscles.     From    wjtnin   outward  the 
trian-le  contains  the  median  nerve,  brachial  artery,  tendon 
of   the  biceps,   anastomosis    of  the   superior  profunda    and 
radial  recurrent  arteries,  and  the  musculospiral  nerve. 

Operations.-Z.V.r//^//  at  the  Bend  of  the  Elbo^v.-\^  this 
operation  (PI.  3,  Fig.  2)  the  patient  is  placed  supine  the  arm 
is  moderated  abducted  and  extended,  and  is  allowed  to  he 
upon  its  posterior  aspect.  The  forearm  is  supmated  The 
surcreon  stands  upon  the  side  operated  upon,  and  cuts  from 
abot-e  downward  on  the  right  side  and  from  below  upward 
on  the  left  side.  The  tendon  of  the  biceps  and  the  median 
basilic  vein  must  be  accurately  located.  An  incision  is  made 
parallel  with  the  inner  edge  of  the  biceps  tendon  and  two 
Lhes  in  length,  the  center  of  this  cut  bemg  m  the  crease 
of  the  elbow.  On  exposing  the  median  basilic  vein  retiact 
it  downward  and  inward,  open  the  bicipital  f^^cia  clear  he 
artery  of  fat,  separate  the  venae  comites.  and  pass  the  ligature 
from  within  outward  to  avoid  the  median  nerve.  The  above 
operation  is  not  frequently  performed. 

Li^ration  in  the  Middle  of  the  Arm.-lx^  this  operation  the 
patient  is  placed  supine,  the  arm  is  abducted,  and  the  forearm 
Fs  su^inate'd.  An  'assistant  holds  the  forearm  but  the  arrn 
should  not  rest  upon  the  table,  because,  ^f/^^e  allowed 
to  do  so.  the  inner  head  of  the  triceps  will  be  forced  for- 
ward and  may  overlie  the  artery,  and  thus  complicate  the 


364   DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

operation.  Locate  the  inner  edge  of  the  biceps,  which  is  the 
guide.  Make  an  incision  three  inches  long  in  the  Hne  of 
the  artery.  Incise  the  skin  and  fascia,  flex  the  elbow 
slightly,  retract  the  biceps  outward,  feel  for  the  artery, 
open  the  sheath,  separate  its  venae  comites,  and,  having 
located  the  median  nerve,  pass  the  ligature  from  it.  In  the 
middle  of  the  arm  the  nerve  is  in  front  of  the  vessel,  above 
the  middle  it  is  external  to  it,  and  below  the  middle  it  is 
internal  to  it.  High  up  the  arm  the  inner  edge  of  the  cor- 
acobrachialis  is  the  guide,  rather  than  the  biceps.  Above 
the  middle  of  the  arm  the  basilic  vein  is  beneath  the  deep 
fascia  and  passes  along  by  the  inner  side  of  the  artery ;  hence, 
high  up,  the  artery  has  three  companion  veins,  the  venae 
comites  and  the  basilic  vein,  and  there  is  seen  the  ulnar  nei-ve 
to  the  inside  of  the  artery. 

Axillary  Artery. — To  determine  the  line  of  the  axillary 
artery  place  the  arm  at  a  right  angle  to  the  body,  with  the 
patient  supine,  and  lay  down  a  line  from  the  middle  of  the 
clavicle  to  the  humerus  near  the  inner  border  of  the  coraco- 
brachialis.  The  line  of  the  third  portion  can  be  approximated 
by  projecting  the  line  of  the  brachial  upward. 

Anatomy  (PI.  3,  Fig.  3  ;  PI.  4,  Fig.  i). — The  axillary  artery 
is  the  continuation  of  the  subclavian,  and  runs  from  the  lower 
margin  of  the  first  rib  to  the  inferior  border  of  the  teres  major 
muscle.  It  is  divided  into  three  portions  by  the  pectoralis 
minor  muscle.  The  first  portion  is  above,  the  second  por- 
tion is  behind,  and  the  third  portion  is  below,  the  pectoralis 
minor.  The  position  of  the  artery  varies  with  the  position 
of  the  limb.  When  the  arm  is  parallel  with  the  body  the 
artery  is  far  from  the  surface  and  forms  a  curve  whose  con- 
vexity is  upward  and  outward.  When  the  arm  is  at  a  right 
angle  to  the  body  the  vessel  is  nearer  the  surface  and 
straight.  When  the  arm  is  raised  above  a  right  angle  the 
artery  comes  near  the  surface  and  forms  a  curve  with  the 
convexity  downward. 

The  first  portion  of  the  axillary  artery  is  occasionally 
ligated.  It  lies  upon  the  first  intercostal  muscle  and  the 
first  serration  of  the  great  serratus  muscle,  and  has  behind 
it  the  posterior  thoracic  nerve ;  the  brachial  plexus  is  exter- 
nal and  posterior  to  the  vessel ;  on  its  inner  side  is  the  axil- 
lary vein ;  in  front  of  it  are  the  clavicle,  the  great  pectoral 
muscle,  the  subclavius  muscle,  the  costocoracoid  membrane, 
the  cephalic  and  acromiothoracic  veins,  and  the  external  an- 
terior thoracic  ner\'e.  The  branches  of  the  first  part  of  the 
axillary  artery  are  the   superior  thoracic  and  the  acromio- 


AXILLARY  ARTERY. 


565 


thoracic      The  second  part  of  the  arter>^  is  not  hgated.     Tne 
brachilT  plexus   surrounds  the  second  portion.     The  third 
nSi    cohered  in  front,  above,  by  the  great  pectoral  but  is 
Sve  ed  be!ow  bv  skin  and  fascia ;  behind,  it  has  the  tendon 
of  the  subscapularis,    the   latissimus   dorsi.    and    the    tere. 
lior  muscles  ;  the  coracobrachialis  is  on  the  outer  side  ;  the 
San  vein  is  on  the  inner  side.     It  is  important  to  remem- 
he    t£t  ?here  mav  be  three  veins,  one  external  and  two 
^'ternaf    The  axillan-  vein  is  formed  by  the  ven^  comites 
of  the  brachial  arten' joining,  and  this  new  vem  effecting  a 
function  with  the  basilic  vem.     The  median  nerve  lies  upon 
ihe  axiUan-  artery  in  the  upper  part  of  the  third  portion  of 
tl  e  ve  4?s  courZ,  and  passes  to  the  outer  side.     The  muscu- 
ocutaneousner^-e  s  external,  but  it  is  only  seen  high  up  ;  the 
ulnar  nen^e  is  internal;  the  lesser  internal  and  the  internal 
cutLous  nen^es  are  internal ;   the  musculospiral  and    the 
drcTi^flex  ner^^es  are  behind.     The  branches  of  the    third 
portrn  of  the  axilW  arter,-  are  the  subscapular  and  the 
anterior  and  posterior  circumflex_  p,    ,    ^-^     ^ 

OxyevaXions.— Ligation  of  the  Third  Poition  [YV.  j,  -f^l^-  4j- 
-tSc  position  of  the  patient  should  be  supme,  with  the 
shoulders  raised  and  the  arm  abducted  to  a  right  angle.     The 
surgeon  stands  bet^veen  the  patients  arm  ^nd.^ide  ^Mt    his 
hart-  toward  the  subiecfs  feet.     An  mcision  is  made  three 
mL  in  lenX     It  begins  half-way  up  the  axilla  opposite  to 
he  head  of  the  humeru?.  and  is  taken  downward  parallel  to 
the  lower  edo-e  of  the  great  pectoral  muscle  and  crosses  the 
tuncSon  of  the  anterior  and  middle  thirds  of  the  outlet  of 
the  axilla.     The  integuments  and  fascia  are   incised,      ihe 
vdn  or  veins  will  be  prominent  to  the  inner  side  and  may 
overlk  thL  vessel.     To  the  inner  side  with  the  veins  are  the 
Snar  and   internal   cutaneous    ner^-es.     The    median   nei-ve 
fupon  a:,"the  external  cutaneous  -/o  the  outer  side  of 
the  art^rv'.     Feel  for  the  pulsations  of  the  arter)',  find  the 
rnedian   nen-e  and  draw  it   outward,  draw  the  nerx^es   and 
^etn      -4h  H;  to  the  inner  side  inward,  clear  the  artery  from 
he  ven^  comites,  and  pass  the  ligature  fromwithm  outward. 
Applv  the  Hgature  well  below  the  circumflex  branches 

Uo-ation  of  the  First  Part. -TX^^s  operation  (PL  4.  Fig- 2) 
was  first  performed  in  1815  by  Chamberlaine  of  Jamaica. 
The  patlen?is  placed  supine,  the  upper  part  of  the  body  being 
raided  a  sand  pillow  being  placed  between  the  scapuke  to 
n  ure  carn-ing  back  of  the  point  of  the  shoulder,  and  the 
arm  being 'brought  down  along  the  side.  In  operating  on 
th^left  side  thelurgeon  stands  on  the  outer  side  of  the  left 


366   DISEASES  AND   INJURIES    OF  HEART  AND    VESSELS. 

arm ;  in  operating  on  the  right  side  he  stands  to  the  right  of 
the  subject's  head  and  leans  over  his  shoulder.  The  incision, 
which  is  slightly  curved  downward,  begins  external  to  the 
sternoclavicular  joint  and  ends  internal  to  the  margin  of  the 
deltoid,  thus  avoiding  the  cephalic  vein.  The  incision  is  half 
an  inch  below  the  clavicle.  Incise  the  skin,  the  platysma 
myoides  muscle,  and  the  deep  fascia.  In  the  outer  angle 
of  the  wound  watch  out  for  the  acromiothoracic  artery 
and  the  cephalic  vein.  Incise  the  pectoralis  major;  draw  the 
pectoralis  minor  downward ;  retract  the  lower  margin  of  the 
wound,  cut  through  the  costocoracoid  membrane  close  to 
the  coracoid  process  and  the  upper  border  of  the  lesser  pec- 
toral muscle.  Bring  the  arm  to  the  side  so  as  to  relax  the 
structures.  Find  the  brachial  plexus,  feel  for  the  artery  inter- 
nal to  it,  clear  the  vessel,  draw  the  vein  internally,  and  pass 
the  needle  from  within  outward.  This  avoids  the  dangerous 
neighbor,  which  is  the  axillary  vein.  This  operation  is 
difficult,  dangerous,  and  unusual,  and  in  its  performance  the 
axillary  vein,  which  has  a  close  attachment  to  the  costo- 
coracoid membrane,  is  apt  to  be  torn. 

Subclavian  Artery. — There  is  no  line  for  this  vessel. 

Anatomy  (PI.  4,  Fig.  i). — The  subclavian  artery  of  the 
right  side  arises  from  the  innominate  ;  that  of  the  left  side,  from 
the  arch  of  the  aorta.  The  subclavian  is  divided  into  three 
parts.  The  first  part  runs  from  the  origin  of  the  vessel  to 
the  inner  border  of  the  scalenus  anticus  muscle;  the  second 
part  lies  behind  the  scalenus  anticus  muscle ;  and  the  third 
part  runs  from  the  outer  edge  of  the  muscle  to  the  lower 
border  of  the  first  rib. 

At  the  present  day  the  first  and  second  portions  are  rarely 
ligated.  The  third  portion  is  contained  in  the  subclavian 
triangle  (Fig.  104J,  and  is  superficial.  It  rises,  as  a  rule,  to 
half  an  inch  above  the  clavicle.  The  subclavian  vein  is  below 
the  artery,  being  separated  from  it  by  the  scalenus  anticus 
muscle.  The  brachial  plexus  is  above  and  external  to  the 
artery.  The  vessel  rests  upon  the  first  rib,  and  behind  it  is 
the  scalenus  medius  muscle.  The  suprascapular  and  trans- 
versalis  colli  arteries  and  veins  and  branches  of  the  cervical 
plexus  of  nerves  lie  in  front  of  the  artery,  and  the  external 
jugular  vein  crosses  it  at  its  inner  side.  The  third  portion 
gives  off  no  branches. 

Ligatio7i  of  the  Third  Part. — This  operation  (PI.  4,  Fig.  2) 
was  first  successfully  performed  in  1 817  by  Post  of  New  York. 
The  patient  is  placed  upon  his  back,  the  shoulders  are  raised, 
the  head  is  extended  and  turned  toward  the  opposite  side,  the 


LIGATIONS. 


Plate  4. 


m?^,^     0. 


<   't; 


V 


o    = 

"5  < 


VEKTEBKAL   ARTERY.  367 

arm  is  pulled  down  and  held  b}'  pushing  the  forearm  under 
the  patient's  back  (Treves).  This  pulls  down  the  clavicle, 
thus  increasing  the  size  of  the  subclavian  triangle.  The 
operator  stands  facing  the  shoulder,  with  his  back  toward 
the  patient's  feet.  The  skin  over  the  subclavian  triangle, 
at  a  point  half  an  inch  above  the  cla\'icle,  is  drawn  down 
until  it  overlies  the  bone  and  is  incised.  This  maneuver 
enables  the  surgeon  to  avoid  the  external  jugular  vein  and 
to  make  an  incision  in  the  skin  half  an  inch  above  the  collar- 
bone. The  incision  reaches  from  the  anterior  edge  of  the 
trapezius  to  the  posterior  border  of  the  sternocleidomastoid 
(PI.  4,  Fig.  2),  and  is  about  three  inches  long.  By  this  in- 
cision are  divided  the  skin,  the  superficial  fascia,  the  platysma 
myoides,  the  vein  running  from  the  cephalic  to  the  external 
jugular,  and  some  superficial  nen^es.  The  deep  fascia  is 
opened.  The  external  jugular  \-ein  is  drawn  into  the  inner 
angle  of  the  wound,  and  is  not  divided  unnecessarily ;  if 
forced  to  divide  the  vein,  tie  with  two  ligatures  and  cut  be- 
tween them.  The  surgeon  seeks  to  find  the  outer  edge  of 
the  anterior  scalene  muscle,  and  runs  the  finger  down  along 
it  to  the  tubercle  on  the  first  rib.  The  posterior  belly  of 
the  omohyoid  muscle  is  drawn  upward  by  an  assistant.  The 
surgeon  with  a  finger  on  the  tubercle  recalls  the  facts  that 
the  vein  is  in  front  of  the  finger  and  the  arter}^  is  behind  it, 
and  that  the  subclavian  vein  is  on  a  lower  plane  than  the 
artery.  The  artery  is  felt  beating  as  it  lies  upon  the  rib. 
The  artery  is  cleared  and  the  lower  cord  of  the  brachial 
plexus  is  exposed.  The  vein  must  be  guarded  with  the 
finger  and  the  needle  is  passed  from  above  downward,  as 
the  plexus,  which  is  in  more  danger  than  the  vein,  is  to  be 
avoided.  In  this  operation  the  transversalis  colli  and  supra- 
scapular arteries  must  not  be  cut,  as  they  are  necessaiy  to 
the  future  anastomotic  circulation.  If  the  field  of  operation 
is  too  small,  the  trapezius  or  sternocleidomastoid,  or  both, 
should  be  incised  transversely. 

The  vertebral  artery  was  first  successful!}-  ligated  b\' 
Smyth  of  New  Orleans. 

Anatomy. — This  vessel  is  the  largest  branch  of  the  sub- 
clavian, and  is  the  first  branch  coming  from  the  first  portion  of 
the  subclavian.  The  vertebral  arter}-  ascends  and  enters  the 
foramen  in  the  transverse  process  of  the  sixth  cervical  ver- 
tebra (in  rare  cases  the  fifth  or  the  seventh),  and  ascends 
through  foramina  in  the  cervical  vertebrae,  passes  behind  the 
articular  process  of  the  atlas  and  over  the  posterior  arch  of 
this  first  vertebra,  pierces  the  posterior  occipito-atloid  liga- 


368   DISEASES  AND  INJURIES   OF  HEART  AND    VESSELS. 

ment,  and  enters  the  skull  by  way  of  the  foramen  magnum 
(see  Gray).  It  joins  its  fellow  of  the  opposite  side  to  form 
the  basilar  artery.  At  its  point  of  origin  the  vertebral  artery 
has  in  front  of  it  the  internal  jugular  vein  and  inferior  thy- 
roid artery.  Gray  says  that  near  the  spine  it  Hes  between 
the  longus  colli  and  scalenus  anticus  muscles,  with  the 
thoracic  duct  to  the  left  and  in  front. 

Ligation. — The  position  of  the  patient  is  the  same  as  for 
ligation  of  the  carotid  artery.  Make  an  incision  three 
inches  in  length  along  the  posterior  edge  of  the  sterno- 
cleidomastoid muscle.  This  incision  reaches  the  clavicle. 
In  dividing  the  skin  and  superficial  fascia  watch  for  the  ex- 
ternal jugular  vein  and  retract  it  inward.  Divide  the  deep 
fascia.  Retract  the  strenocleidomastoid  muscle  inward. 
Open  the  space  between  the  longus  colli  and  scalenus  anticus 
muscles,  find  the  artery,  clear  it,  and  pass  the  needle  from 
the  inner  side.  Jacobson  tells  us  to  remember  that  the 
phrenic  nerve  lies  on  the  scalene  muscle,  the  pleura  is  inter- 
nal, the  internal  jugular,  inferior  thyroid,  and  vertebral  veins 
are  over  the  vessel,  and  the  thoracic  duct  on  the  left  side 
crosses  it  from  within  outward. 

The  Inferior  Thyroid  Artery. — Anatomy. — The  infe- 
rior thyroid  artery  is  a  branch  of  the  thyroid  axis.  It  ascends 
the  neck,  passes  back  of  the  carotid  sheath  and  the  sympathetic 
nerve,  and  reaches  the  thyroid  gland.  The  recurrent  laryn- 
geal nerve  lies  behind  the  artery.  The  phrenic  nerve  is 
external  to  the  artery  and  near  to  it  in  the  first  part  of  its 
course  (up  to  the  point  of  origin  of  the  ascending  cervical 
branch).  The  ascending  cervical  branch  takes  origin  just 
before  the  artery  begins  to  dip  behind  the  carotid.  In  front 
of  the  beginning  of  the  inferior  thyroid  artery  of  the  left  side 
the  thoracic  duct  crosses.  The  artery  is  ligated  in  the  second 
part  of  its  course  (between  its  distribution  and  the  origin  of 
the  above-named  branch). 

Ligation. — The  position  of  patient  and  the  incision  are  the 
same  as  for  the  ligation  of  the  common  carotid  artery  in 
the  triangle  of  necessity  (p.  372).  After  exposing  the  sterno- 
cleidomastoid muscle  retract  it  outward,  and  then  draw  out- 
ward the  common  carotid  artery  and  also  the  internal  jugular 
vein.  The  superior  thyroid  artery  will  be  found  a  little  below 
the  carotid  tubercle.  It  is  cleared  and  ligated.  Treves  ad- 
vises licfation  close  to  the  level  of  the  carotid,  so  as  to  avoid 
the  recurrent  laryngeal  nerve. 

Innominate  Artery.  —  First  successfully  ligated  by 
Smyth  of  New  Orleans.     It  is  an  extremely  fatal  operation. 


REGION  OF  THE  NECK.  369 

Anatomy. — The  innominate  artery  arises  from  the  begin- 
ning of  the  transverse  portion  of  the  arch  of  the  aorta,  passes 
to  the  back  of  the  right  sternoclavicular  joint,  and  divides  into 
the  common  carotid  and  subclavian  vessels.  It  rests  upon 
the  trachea.  It  has  upon  its  outer  side  the  pleura,  the  right 
innominate  vein,  and  the  pneumogastric  nerve.  Upon  its  inner 
side  are  the  remnant  of  the  thymus  gland  and  the  beginning 
of  the  left  carotid  artery.  In  front  of  it  are  the  inferior  thyroid 
veins  of  the  right  side,  the  left  innominate  vein,  the  sterno- 
hyoid and  sternothyroid  muscles,  the  remnant  of  the  thymus 
gland,  and  sometimes  a  branch  from  the  right  pneumogastric 
nerve. 

Ligation. — The  patient  is  placed  supine,  with  the  shoulders 
a  little  raised,  and  the  head  thrown  back.  An  incision  is 
carried  from  the  upper  margin  of  the  sternum  for  three  inches 
along  the  anterior  margin  of  the  sternomastoid.  Another 
cut  of  the  same  length  is  made  along  the  upper  border  of 
the  clavicle  to  meet  the  first  cut.  Dissect  up  the  flap  of 
skin  and  fascia.  Divide  the  sternal  origin  and  a  part  of  the 
clavicular  portion  of  the  sternocleidomastoid  muscle,  and 
cut  the  sternohyoid  and  sternothyroid  muscles  just  above 
their  sternal  origins  (Joseph  Bell).  Retract  the  inferior  thy- 
roid veins.  Divide  the  dense  leaflet  of  cervical  fascia.  Find 
the  common  carotid  artery,  and  trace  back  along  this  \'essel 
until  the  innominate  comes  into  view.  Retract  the  left  innom- 
inate vein  downward.  The  needle  is  passed  from  without 
inward  to  avoid  the  right  innominate  vein  and  right  pneu- 
mogastric nerve.  If  the  needle  is  kept  close  to  the  artery, 
the  pleura  and  trachea  Avill  not  be  injured.^ 

Region  of  the  Neck. — Anatomy. — The  side  of  the  neck 
is  that  space  between  the  median  line  in  front  and  the  anterior 
edge  of  the  trapezius  muscle  behind,  which  space  is  limited 
below  by  the  clavicle  and  above  by  the  body  of  the  jaw  and 
an  imaginary  Hne  running  from  the  angle  of  the  jaw  to  the 
mastoid  process.  The  sternocleidomastoid  muscle  divides 
this  space  into  an  anterior  and  a  posterior  triangle,  and  each 
of  the  triangles  is  subdivided  by  other  structures,  the  ante- 
rior into  four  spaces  and  the  posterior  into  two  (Fig.  104). 

Anterior  Triangle. — The  anterior  triangle  is  bounded  in 
front  by  the  median  line  of  the  neck,  behind  by  the  anterior 
margin  of  the  sternocleidomastoid  muscle,  and  above  by  the 
body  of  the  low^er  jaw  and  an  imaginar}'  line  drawn  from 
the  angle  of  the  jaw  to  the  mastoid  process.      This   space 

^  See  the  exceedingly  clear  and  terse  account  in  that  excellent  book,  A  Man- 
tial  of  Sui-gical  Operations,  by  Joseph  Bell. 

24 


370  DISEASES  AND   INJURIES    OF  HEART  AND    VESSELS. 


is  subdivided  into  four  smaller  triangles,  namely,  the  inferior 
carotid,  the  superior  carotid,  the  submaxillary,  and  the  sub- 
mental. 

The   inferior  carotid  triangle  is   called   the  "  triangle   of 
necessity,"  because  the  common  carotid  artery  in  this  region 

is  ligated,  not  from  choice,  but 
through  force  of  necessity.  It  is 
bounded  in  front  by  the  median 
hne,  above  by  the  anterior  belly 
of  the  omohyoid  muscle  and  the 
hyoid  bone,  and  below  by  the  an- 
terior edge  of  the  sternomastoid 
muscle.  The  floor  of  this  triangle 
is  composed  of  the  longus  colli, 
the  scalenus  anticus,  the  rectus 
capitis  anticus  major,  the  sterno- 
hyoid, and  sternothyroid  muscles. 
The  superior  carotid  triangle  is 
known  as  the  "  triangle  of  elec- 
tion," because,  if  the  carotid  artery 
must  be  tied,  the  surgeon,  when- 
ever possible,  elects  or  chooses 
to  tie  it  in  this  triangle.  In  this 
region  the  carotid  is  superficial, 
and  there  can  be  tied  either  the 
external,  the  internal,  or  the  com- 
may  be  desired.  The  triangle  is 
anterior  edee  of  the  sternocleido- 


FiG.  104. — The  triangles  of  the 
neck,  right-sided  view  (after  Keen)  : 
I,  submaxillary  triangle  ;  2,  "  triangle 
of  election,"  or  superior  carotid  tri- 
angle ;  3,  submental  triangle ;  4, 
"triangle  of  necessity,"  or  inferior 
carotid  triangle ;  5,  occipital  trian- 
gle :  6,  subclavian  triangle ;  7,  hy- 
oid  bone. 


mon    carotid    artery,   as 

bounded  behind  by  the 

mastoid,  above  by  the  posterior  belly  of  the  digastric,  and 

below  by  the  anterior  belly  of  the  omohyoid  muscles.     Its 

floor  is  composed  of  the    inferior  and  middle  constrictors 

of  the  pharynx  and  the  thyrohyoid  and  hyoglossus  muscles. 

The  submaxillary  triangle  is  bounded  above  by  the  body 
of  the  jaw  and  an  imaginary  line  drawn  from  the  angle  of 
the  jaw  to  the  mastoid  process,  behind  by  the  posterior 
belly  of  the  digastric  muscle  and  the  stylohyoid  muscle, 
and  in  front  by  the  anterior  belly  of  the  digastric  muscle. 
Its  floor  is  composed  of  the  mylohyoid  and  hyoglossus 
muscles. 

The  submental  triangle  is  bounded  on  either  side  by  the 
anterior  belly  of  one  digastric  muscle  ;  its  base  is  the  hyoid 
bone  and  its  floor  is  the  mylohyoid  muscle. 

The  posterior  triangle  is  bounded  in  front  by  the  posterior 
border  of  the  sternocleidomastoid  muscle,  behind  by  the  an- 
terior edge  of  the  trapezius  muscle,  and  below  by  the  clav- 


COMMON  CAROTID  ARTERY.  37 1 

icle.  The  posterior  belly  of  the  omohyoid  muscle  subdivides 
it  into  two  smaller  spaces,  the  occipital  and  subclavian  tri- 
angles. 

The  occipital  triangle  is  bounded  in  front  by  the  posterior 
edge  of  the  sternocleidomastoid  muscle,  behind  by  the  ante- 
rior border  of  the  trapezius  muscle,  and  below  by  the  pos- 
terior belly  of  the  omohyoid  muscle. 

The  subclavian  triangle  is  bounded  above  by  the  posterior 
belly  of  the  omohyoid  muscle,  below  by  the  clavicle,  and  in 
front  by  the  posterior  border  of  the  sternocleidomastoid 
muscle.  Its  floor  is  formed  by  the  first  rib  and  the  first 
serration   of  the  serratus   magnus   muscle. 

Common  Carotid  Artery. — The  line  of  the  common 
carotid  artery  is  from  the  sternoclavicular  articulation  to  mid- 
way between  the  angle  of  the  jaw  and  the  mastoid  process, 
the  head  being  turned  toward  the  opposite  side. 

Anatomy  (PL  4,  Fig.  3). — The  right  common  carotid 
arises  from  the  innominate  opposite  the  sternoclavicular 
joint;  the  left  common  carotid  arises  from  the  arch  of  the 
aorta.  In  the  neck  the  two  carotids  possess  identical  rela- 
tions. The  common  carotid  runs  upward  and  outward  from 
behind  the  sternoclavicular  articulation  to  a  level  with  the 
upper  border  of  the  thyroid  cartilage,  at  which  point  it  divides 
into  the  external  and  internal  carotid.  The  common  carotid 
is  contained  in  a  sheath  derived  from  the  cervical  fascia. 
This  sheath  also  contains,  in  separate  compartments,  the  in- 
ternal jugular  vein  on  the  outer  side  of  the  artery  and  the 
pneumogastric  nerve  between  the  vein  and  artery,  but  more 
deeply  placed.  The  anterior  edge  of  the  sternocleidomastoid 
muscle  lies  over  the  artery  and  is  a  guide.  Low  in  the  neck 
the  common  carotid  is  deep,  being  covered  by  skin,  super- 
ficial fascia,  platysma,  deep  fascia,  and  the  sternocleidomas- 
toid, sternohyoid,  and  sternothyroid  muscles.  Above  the 
omohyoid  muscle  the  vessel  is  more  superficial,  being  cov- 
ered by  the  skin,  superficial  fascia,  platysma,  deep  fascia,  and 
the  anterior  edge  of  the  sternocleidomastoid  muscle.  Upon 
the  sheath  (occasionally  within  it),  above  the  crossing  of  the 
omohyoid  muscle,  Hes  the  descendens  noni  nerve — the  de- 
scending branch  of  the  ninth  pair  of  Willis  (the  hypoglossal). 
This  nerve  is  a  valuable  guide  to  the  sheath  in  the  triangle 
of  election. 

The  sternoniastoid  branch  of  the  superior  thyroid  artery 
crosses  the  carotid  artery  a  little  below  its  bifurcation,  and  the 
superior  thyroid  vein  also  crosses  it  in  this  region  ;  the  middle 
thyroid  vein  crosses  the  artery  near  its  middle,  and  the  ante- 


372   DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

rior  jugular  vein  crosses  low  down.  The  common  carotid  rests 
upon  the  longus  colli  and  rectus  capitis  anticus  major  muscles, 
the  sympathetic  nerve  lying  between  the  last-named  muscle 
and  the  vessel,  outside  the  carotid  sheath.  The  recurrent  lar- 
yngeal nerve  passes  behind  the  carotid  below  the  omohyoid 
muscle,  and  the  inferior  thyroid  artery  passes  behind  the  caro- 
tid just  above  the  omohyoid  muscle.  The  common  carotid  is 
in  relation  internally  with  the  trachea,  thyroid  gland,  larynx, 
and  pharynx.  To  the  outer  side  are  the  pneumogastric  nerve 
(which  is  on  a  posterior  plane)  and  the  internal  jugular  vein. 
On  the  left  side,  low  down  in  the  neck,  the  jugular  vein  often 
lies  in  front,  or  partly  in  front,  of  the  artery.  Ligation  of  the 
common  carotid  was  first  successfully  performed  in  1806  by 
Sir  Astley  Cooper. 

Ligation  in  the  Triangle  of  Necessity. — In  this  operation  the 
patient  is  placed  supine,  with  the  shoulders  raised,  a  sand- 
pillow  under  the  neck,  and  the  head  turned  to  the  opposite 
side,  with  the  chin  raised.  The  operator  stands  upon  the  side 
operated  upon.  The  incision,  three  inches  long,  at  a  slight 
angle  to  the  arterial  line,  runs  from  the  level  of  the  cricoid 
cartilage  downward  and  inward  toward  the  sternoclavicular 
joint,  following  the  inner  border  of  the  sternocleidomastoid 
muscle.  The  surgeon  opens  the  deep  fascia,  draws  the 
sternocleidomastoid  outward,  retracts  the  sternohyoid  and 
sternothyroid  muscles  inward,  and  feels  for  the  carotid  tuber- 
cle of  Chassaignac.  This  tubercle  is  the  costal  process  of 
the  sixth  cervical  vertebra,  and  lies  directly  under  the  artery. 
The  tubercle  is  found  about  the  point  at  which  the  omo- 
hyoid crosses  the  carotid.  When  the  tubercle  is  found  we 
know  the  situation  of  the  artery,  and  that  the  triangle  of 
necessity  is  below,  and  the  triangle  of  election  above,  the 
tubercle.  The  operator  draws  the  omohyoid  muscle  upward, 
opens  the  sheath  of  the  arteiy  on  its  inner  side,  clears  the  ves- 
sel, and  passes  the  needle  from  without  inward  to  avoid  the 
internal  jugular  vein,  remembering  that  the  pneumogastric 
nerve  is  in  the  same  sheath  as  the  artery  and  vein,  pos- 
terior and  external  to  the  artery.  In  this  operation  the  in- 
ferior thyroid  veins  are  much  in  the  way,  the  anterior  jugular 
vein  crosses  low  down,  and  on  the  left  side,  at  the  root  of  the 
neck,  the  internal  jugular  vein  may  be  in  front  of  the  carotid 
artery.  If  the  incision  is  not  sufficiently  wide,  partially  divide 
the  sternocleidomastoid  or  the  sternohyoid  and  thyroid  mus- 
cles. In  the  triangle  of  necessity  the  descendens  noni  nerve 
does  not  serve  as  a  guide  to  the  sheath  of  the  vessels.  (See 
PI.  4,  Fig.  4.) 


EXTERXAL    CAROTID  ARTERY.  373 

Lio-ation  in  the  Triangle  of  Election.— X\^^  position  of  the 
patient  for  this  operation  is  the  same  as  in  the  preceding  one. 
An  Incision,  three  inches  in  length,  is  made  along  the  anterior 
edcre  of  the  sternocleidomastoid  muscle  in  the  line  ot  the 
arterv  the  middle  of  this  incision  being  opposite  the  cricoid 
cartilage.    In  cutting  the  superficial  fascia  the  surgeon  a^-Olds 
the  external  jugular  vein,  the  course  of  which  should  be 
outln^ed  before  making  the  incision.    The  line  o   the  external 
iu-ular  is  from  the  angle  of  the  jaw  to  the  middle  of  the  clav- 
icl?    The  operator  opens  the  deep  fascia,  retracts  the  sterno- 
cleidomastcJid  muscle  outward,  feels  for  the  carotid  tubercle, 
draws  the  omohyoid  muscle  downward,  finds  the  descendens 
noni  nerve  upon  the  sheath,  opens  the  sheath  at  its  inner  side, 
and  passes  the  needle  from  without  inward.    This  incision  per- 
mits ligation  of  either  the  superior  thyroid  or  the  externa    in- 
ternal  or  common  carotid,  and  if  it  be  extended  up  a  little 
there  can  be  tied  through  it  the  lingual,  and  even  the  taciai 
and  occipital,  arteries.     (See  PI.  4.  Fig.  4-) 

Bxtemal   Carotid   Artery.-The  line  of  the  external 
carotid  artery  is  the  upper  portion  of  the  common  carotid 

^'"Inatomy   (PI  4,  Fig.   3)--The   external   carotid   arteiy, 
which  is  one  of  the  terminal  branches  of  the  common  carotid, 
arises  on  a  level  with  the  upper  border  of  the  thyroid  car  ilage 
and  runs  to  the  level  of  the  neck  of  the  condyle  of  the  lower 
iaw    At  its  point  of  origin  it  is  covered  only  by  skin,  plat>^sma, 
and  fascia  and  the  edge  of  the  sternomastoid.  but  as  it  ascends 
it  passes  beneath  the  digastric  and  stylohyoid  muscles  and 
into  the  parotid  gland.     The  glossopharyngeal  nen^e,  styloid 
process  and  st^dophar^mgeus  muscle  he  between  the  external 
^d Internal  carotfd  arteries.     The  hypoglossal  ner^^e  crosses 
the  vessel  just  below  the  digastric  muscle,  and  the  facial  and 
hn-ual  veins  cross  it  a  little    below    the   neije.     The   fir.t 
branch  is  the  superior  thyroid  which  arises  from  the  ^^ry 
beginning  of  the  trunk.     The  lingual  arises  on  a  level  with 
the  "-^at^er  cornu  of  the  hyoid  bone.  The  facial  and  occipital 
take^rigin  above  the  lingual.     Each  of  them  can  be  ligated 
throucrh  the  incision  of  this  operation. 

Operation.-Place  the  patient  in  the  same  position^,  foi 
hgadon  of  the  common  carotid^  The  P°f  /  .^^l^%"  " 
b?tween  the  superior  thyroid  and  the  hngual  arterie.^  Make 
an  incision  three  inches  in  length  at  a  slight  angle  o  he 
arterial  hne.  from  near  the  angle  of  the  jaw  to  oppo^te  the 
middle  of  the  thyroid  cartilage  Cut  through  the  skin 
superficial   fascia,   platysma,    and    deep   fascia,    and    retract 


374   DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

the  sternocleidomastoid  muscle  outward.  Watch  for  the 
digastric  muscle,  find  the  hypoglossal  nerve,  and  feel  for 
the  greater  cornu  of  the  hyoid  bone.  Open  the  sheath  a 
little  below  the  hyoid  cornu  and  pass  the  needle  from  with- 
out inward.  Ligation  of  the  external  carotid  has  been  neg- 
lected because  ligation  of  the  common  carotid  is  easier. 

Internal  Carotid  Artery. — The  line  of  the  internal 
carotid  is  parallel  with  and  half  an  inch  external  to  the 
line  of  the  external  carotid. 

Anatomy  (PI.  4,  Fig.  3). — The  internal  carotid  artery,  the 
other  terminal  branch  of  the  common  carotid,  arises  on  a  level 
with  the  upper  border  of  the  thyroid  cartilage  and  enters  the 
carotid  canal.  The  first  inch  of  the  artery  is  the  only  point 
where  a  ligature  is  ever  applied,  this  point  being  covered  only 
by  skin,  platysma,  fascia,  and  the  sternocleidomastoid  mus- 
cle ;  higher  up  it  is  more  deeply  placed.  It  rests  upon  the 
vertebrae  and  the  rectus  capitis  anticus  major  muscle.  The 
internal  jugular  vein  is  in  the  same  sheath  and  external  to 
the  artery ;  the  pneumogastric  is  in  the  same  sheath,  between 
the  artery  and  the  vein,  but  posterior  to  both.  The  superior 
cervical  ganglion  of  the  sympathetic  lies  behind  the  origin  of 
the  internal  carotid,  and  between  the  ganglion  and  the  artery 
is  the  superior  laryngeal  nerve. 

Operation. — In  this  operation  the  position  of  the  patient 
is  the  same  as  for  ligation  of  the  external  carotid.  The  in- 
cision is  of  the  same  length  and  direction  as  that  for  ligation 
of  the  external  carotid,  and  is  half  an  inch  external.  The 
sternocleidomastoid  muscle  is  drawn  outward,  the  external 
carotid  artery  is  found  and  drawn  inward,  the  internal  caro- 
tid is  found  and  cleared,  and  the  needle  is  passed  from 
without  inward.  The  internal  carotid  is  known  by  its 
more  external  position  and  by  the  fact  that  it  gives  off  no 
branches. 

Superior  Thyroid  Artery  (PI.  4,  Fig.  3). — This  branches 
off  from  the  external  carotid  below  the  level  of  the  greater 
cornu  of  the  hyoid  bone,  in  the  triangle  of  election.  It  is  at 
first  superficial,  runs  first  upward  and  inward,  next  downward 
and  forward,  passes  underneath  the  omohyoid,  sternohyoid, 
and  sternothyroid  muscles,  and  reaches  the  thyroid  gland. 

Ligation. — The  position  of  the  patient  and  of  the  surgeon  is 
the  same  as  for  carotid  ligation.  The  artery  may  be  reached 
through  the  incision  employed  for  ligation  of  the  external 
carotid.  Gross  employed  an  incision  beginning  at  the  edge 
of  the  hyoid  bone,  and  running  downward  and  outward  to 
the  sternomastoid  muscle.    The  skin  and  superficial  and  deep 


FACIAL   ARTERY.  375 

fascicne  are  divided,  and  the  arter)'  is  found  deeply  placed  in 
the  triangle  of  election  between  the  carotid  sheath  and  the 
thyroid  g^land. 

I/ingriial  Artery. — Anatomy  (PI.  4,  Fig.  3). — The  lingual 
artery  arises  from  the  external  carotid  opposite  the  greater 
cornu  of  the  hyoid  bone,  passes  beneath  the  digastric  and 
stylohyoid  muscles,  reaches  the  margin  of  the  hyoglossus 
muscle,  passes  under  that  muscle,  and  emerges  from  beneath 
it  to  run  along  the  under  surface  of  the  tongue.  The  place 
of  election  for  ligation  is  where  the  artery  is  beneath  the 
hyoglossus  muscle.  Its  guide  is  the  hypoglossal  nerve,  which 
lies  upon  the  muscle,  but  at  a  slightly  higher  level  than  the 
artery. 

Operation. — In  this  operation  the  patient  is  placed  re- 
cumbent with  the  shoulders  raised  and  the  face  turned 
away  from  the  side  to  be  operated  upon.  The  surgeon 
stands  upon  the  affected  side.  A  curved  incision  is  made 
from  a  little  external  to  the  symphysis  of  the  low^er  jaw, 
downward  and  outward,  to  just  above  the  greater  cornu 
of  the  hyoid  bone,  and  upward  and  outward  to  just  in  front 
of  the  facial  artery  at  the  lower  edge  of  the  lower  jaw.  The 
skin,  the  superficial  fascia  and  platysma,  and  the  deep  fascia 
are  incised.  The  submaxillary  gland  is  cleared  and  retracted 
well  upward.  The  fascia  below  the  gland  is  divided  by  a 
transverse  incision.  The  posterior  edge  of  the  mylohyoid 
muscle  and  the  bellies  of  the  digastric  muscle  are  sought 
for  and  identified.  One  of  the  digastric  tendons  is  retracted 
down  and  out  (Treves).  The  hyoglossus  muscle  is  cleared 
with  a  dissector  ;  the  hypoglossal  nerve  and  ranine  vein  are 
found  and  drawn  a  little  upward.  The  hyoglossus  muscle 
is  divided  transversely  a  little  above  the  hyoid  bone  and 
below  the  level  of  the  hypoglossal  nerve.  The  arter}^  is 
found  under  the  muscle  and  the  needle  is  passed  from  above 
downward. 

Facial  Artery. — Anatomy  (PL  4,  Fig.  3). — Arises  from 
the  external  carotid  a  little  above  the  lingual,  runs  upward 
and  forward  beneath  the  body  of  the  inferior  maxillary  bone, 
passes  along  a  groove  in  the  posterior  and  upper  surface  of 
the  submaxillary  gland,  crosses  the  body  of  the  loAver  jaw  at 
the  lower  anterior  edge  of  the  masseter  muscle,  and  passes 
forward  and  upward  to  the  angle  of  the  mouth  and  side  of 
the  nose. 

Ligation  (PL  4,  Fig.  4). — The  facial  artery  is  rarely  ligated 
in  the  cervical  portion,  but  may  be  reached  through  the 
incision  employed  for  ligation  of  the  external  carotid.     The 


3/6    DISEASES  AND   INJURIES    OF  HEART  AND    VESSELS. 

vessel  ma}^  be  tied  before  it  crosses  the  submaxillary  gland, 
the  stylohyoid  and  digastric  muscles  being  drawn  aside. 
The  vessel  is  reached  in  the  facial  portion  of  its  course  by 
a  one-inch  cut  at  the  anterior  edge  of  the  masseter  mus- 
cle. Branches  of  the  facial  nerve  are  pushed  aside.  The 
needle  is  passed  from  behind  forward  to  avoid  the  vein 
(Jacobson). 

Temporal  Artery. — The  line  of  the  temporal  artery 
passes  "  upward  over  the  root  of  the  zygoma,  midway  be- 
tween the  condyle  of  the  jaw  and  the  tragus  "  (Jacobson). 

Anatomy. — The  temporal  artery  arises  from  the  external 
carotid  behind  the  condyle  of  the  jaw  and  in  the  parotid 
gland,  passes  over  the  zygoma,  and  divides  into  two  terminal 
branches. 

Ligation. — The  patient  is  placed  recumbent  and  the  head  is 
turned  to  the  opposite  side.  An  incision  an  inch  in  length 
is  made,  the  superficial  structures  and  dense  fascia  are 
divided,  the  vein  is  retracted  backward,  and  the  needle  is 
passed  from  behind  forward. 

Occipital  Artery. — Takes  origin  from  the  posterior  sur- 
face of  the  external  carotid,  below  the  digastric  muscle  and 
opposite  the  point  of  origin  of  the  facial  artery.  It  ascends 
beneath  the  digastric  and  stylohyoid  muscles  and  parotid 
gland  ;  the  hypoglossal  nei^ve  hooks  around  it  from  behind 
forward.  It  crosses  the  internal  carotid  artery,  the  internal 
jugular  vein,  the  pneumogastric  and  spinal  accessory  nerves  ; 
passes  between  the  mastoid  process  of  the  temporal  bone 
and  the  atlas ;  grooves  the  temporal  bones ;  penetrates  the 
trapezius  muscle,  and  ascends  over  the  occiput. 

Ligation. — This  vessel  can  be  ligated  near  its  origin  through 
the  same  incision  as  is  employed  to  reach  the  external  caro- 
tid. The  hypoglossal  nerve  is  avoided.  To  tie  back  of  the 
mastoid  process,  place  the  patient  in  the  same  position  as  for 
ligation  of  the  carotid.  Carry  an  incision  from  the  tip  of 
the  mastoid  upward  and  backward,  reaching  a  point  midway 
between  the  mastoid  and  the  occipital  protuberance  (Jacob- 
son).  Cut  the  skin,  the  fascia,  the  sternocleidomastoid,  the 
splenius  capitis,  and  possibly  a  portion  of  the  trachelomas- 
toid  muscles.  Bring  the  head  toward  the  operator  in  order 
to  relax  the  structures,  retract  the  edges  of  the  wound,  and 
clear  the  artery  where  it  lies  between  the  mastoid  process 
and  the  transverse  process  of  the  atlas  (Jacobson).  An  elec- 
tric forehead-light  is  of  great  assistance  in  finding  the  vessel. 
Pass  the  needle  away  from  the  vein  or  veins  (there  are  often 
several). 


LIGATIONS. 


Plate  5. 


/ 


-X^^ 


ANTERIOR    TIBIAL   ARTERY.  377 

Dorsalis  Pedis  Artery. — The  line  of  the  clorsaHs  pedis 
artery  is  from  the  middle  of  the  front  of  the  ankle-joint  to 
the  middle  of  the  base  of  the  first  interosseous  space. 

Anatomy  (PI.  5,  Fig.  i). — The  dorsalis  pedis  is  a  continu- 
ation of  the  anterior  tibial  artery,  and  it  runs  from  the  bend 
of  the  ankle  to  the  proximal  extremity  of  the  first  interosse- 
ous space,  where  it  divides  into  the  dorsalis  hallucis  and  the 
communicating  arteries.  The  artery  rests,  from  above  down- 
ward, upon  the  astragalus,  scaphoid,  and  internal  cuneiform 
bones,  and  at  its  point  of  bifurcation  lies  between  the  heads 
of  the  first  dorsal  interosseous  muscle.  It  may  lie  in  some 
persons  a  little  external  to  this  course.  It  is  held  upon  the 
bones  by  a  distinct  layer  derived  from  the  deep  fascia.  This 
artery  is  covered  by  skin,  by  superficial  and  deep  fascia,  and 
by  the  annular  ligament  above,  and  is  sometimes  partly  over- 
laid by  the  extensor  proprius  pollicis  muscle,  and  is  crossed, 
just  before  its  bifurcation,  by  the  innermost  tendon  of  the  ex- 
tensor brevis  muscle.  The  inner  tendon  of  the  extensor  com- 
munis digitorum  is  to  the  outer  side  of  the  vessel;  the  tendon 
of  the  extensor  proprius  pollicis  is  to  the  inner  side,  and  is  a 
guide.  The  artery  is  ligated  in  the  dorsal  triangle  of  the  foot — 
a  space  which  is  bounded  above  by  the  lower  edge  of  the  an- 
nular ligament,  externally  by  the  inner  tendon  of  the  extensor 
brevis,  and  internally  by  the  tendon  of  the  extensor  proprius 
pollicis.  The  artery  has  venae  comites ;  the  anterior  tibial 
nerv^e  lies,  as  a  rule,  to  its  inner  side,  but  may  be  found  upon 
the  artery  or  to  its  outer  side,  and  the  inner  division  of  the 
musculocutaneous  nerve  is  external  to  the  vessel  in  the 
superficial  parts. 

Operation  (PI.  5,  Fig.  2). — In  this  operation  the  patient  is 
placed  supine  with  the  leg  and  foot  extended.  Heath  flexes 
the  leg  partly  and  rests  the  sole  of  the  foot  directly  upon 
the  table.  The  surgeon  stands  below  the  extremit}^  and 
cuts  from  above  downward.  Make  an  incision  two  inches 
in  length  along  the  arterial  line,  beginning  opposite  the  lower 
edge  of  the  annular  ligament  and  running  along  by  the  tendon 
of  the  extensor  proprius  pollicis ;  cut  through  the  skin  and 
superficial  and  deep  fascia ;  have  the  toes  extended  ;  retract 
the  tendon  of  the  extensor  proprius  pollicis  inward,  and  the 
tendon  of  the  extensor  communis  digitorum  outward ;  clear 
the  artery,  find  the  nerve,  try  to  separate  the  vense  comites, 
and  pass  the  needle  from  the  nerve. 

Anterior  Tibial  Artery. — To  locate  the  line  of  the 
anterior  tibial,  mark  a  point  midway  between  the  head  of 
the  fibula  and  the  tuberosity  of  the  tibia,  drop  one  inch,  and 


378    DISEASES  AND   INJURIES    OF  HEART  AND    VESSELS. 

draw  a  line  from  the  second  point  to  the  middle  of  the  front 
of  the  ankle-joint. 

Anatomy. — The  anterior  tibial  artery  is  one  of  the  termi- 
nal branches  of  the  popliteal.  It  arises  opposite  the  lower 
border  of  the  popliteus  muscle,  passes  forward  between  the 
two  heads  of  the  posterior  tibial  muscle,  comes  to  the  front 
of  the  leg  through  an  opening  in  the  interosseous  mem- 
brane, and  runs  down  to  the  middle  of  the  front  of  the 
ankle-joint.  In  the  upper  two-thirds  of  its  course  it  rests 
upon  the  interosseous  membrane,  to  which  it  is  fastened  by 
firm  fascia;  in  the  lower  third  it  lies  first  upon  the  front  of 
the  tibia  and  then  upon  the  anterior  ligament  of  the  ankle- 
joint.  For  its  upper  two-thirds  the  artery  has  the  tibialis 
anticus  muscle  just  internal  to  it;  at  the  junction  of  the 
middle  and  lower  thirds  the  extensor  proprius  pollicis  comes 
from  the  outside  and  lies  either  upon  the  artery  or  to  its 
inner  side  for  the  rest  of  its  course.  Externally  in  its  upper 
third  is  the  extensor  communis  digitorum,  in  the  middle  third 
is  the  extensor  proprius  pollicis ;  in  the  lower  third,  the 
proprius  pollicis  having  crossed  to  the  inner  side,  the  ex- 
tensor communis  digitorum  again  becomes  the  outer  boun- 
dary. The  artery  is  covered  by  skin  and  by  superficial  and 
deep  fascia.  In  its  upper  third  it  is  deeply  placed  between  the 
muscles  ;  in  its  middle  third  it  is  less  overlaid  by  muscle  ;  in 
its  lower  third  it  is  superficial  except  where  it  is  crossed  by 
the  extensor  proprius  and  where  it  is  covered  by  the  annular 
ligament.  The  artery  has  venae  comites.  In  the  lower  three- 
fourths  of  its  course  it  is  accompanied  by  the  anterior  tibial 
nerve,  which  in  its  course  in  the  upper  third  of  the  leg  is 
external  to  the  artery ;  in  the  middle  third  it  is  external  and 
a  little  in  front  of  the  artery ;  and  in  the  lower  third  it  is  ex- 
ternal to  or  upon  the  artery  (PI.  4,  Fig.  5). 

Operations. — The  ligations  of  the  anterior  tibial  (PI.  4, 
Fig.  6)  are  (i)  of  the  lower  third;  (2)  of  the  middle  third; 
and  (3)  of  the  upper  third.  In  all  these  ligations  the  patient 
is  placed  recumbent  with  the  leg  extended,  and  the  surgeon 
stands  to  the  outer  side  of  the  extremity,  cutting  from  above 
downward  on  the  right  side  and  from  below  upward  on  the 
left  side. 

Ligatiojt  of  the  Lower  Third. — Make  an  incision  three 
inches  long  in  the  line  of  the  artery  and  over  the  annular 
ligament.  This  incision  is  external  to  the  tibialis  anticus 
muscle  and  half  an  inch  from  the  outer  border  of  the  tibia 
(Barker).  Divide  the  skin  and  fascia,  retract  the  tendon  of 
the  tibialis  anticus  inward,  and  the  tendon  of  the  extensor 


POSTERIOR    TIBIAL   ARTERY.  379 

proprius  pollicis  outward,  along  with  the  tendons  of  the 
extensor  communis.  Flex  the  ankle-joint  to  relax  the  ten- 
dons, and  clear  the  artery.  Draw  the  nerve  external  and 
pass  the  ligature  from  without  inward.  In  order  to  recog- 
nize the  muscles  in  this  as  in  other  ligations,  rely  largely 
upon  the  finger  while  the  muscles  are  being  moved. 

Ligation  of  the  Middle  Third. — In  this  operation  the  pro- 
cedure is  similar  to  the  above.  Remember  that  the  nerve  lies 
in  front  of  the  vessel  and  that  the  extensor  proprius  pollicis 
muscle  is  external.  The  ner\^e  is  retracted  outward  and  the 
needle  is  passed  from  the  nerve.  A  good  rule  for  detecting 
the  artery  is  to  find  the  outer  edge  of  the  tibia  and  by  this 
locate  the  interosseous  membrane,  and  then,  by  passing  out 
along  this  membrane,  discover  the  arter}-. 

Ligation  of  the  Upper  TJiird. — Make  an  incision  three 
inches  long  in  the  arterial  line.  On  opening  the  deep  fascia, 
do  not  rely  on  the  eye  for  finding  the  muscular  interspace, 
as  often  the  latter  cannot  be  seen,  and  neither  a  white  nor  a 
yellow  line  is  reliable.  Place  the  index-finger  deep  in  the 
wound  and  have  the  tibialis  anticus  and  extensor  communis 
digitorum  muscles  successiveh^  rendered  tense  by  an  assist- 
ant. In  opening  the  interspace  use  the  handle  of  the  knife. 
Relax  the  muscles,  retract  the  tibialis  anticus  inward,  and 
draw  the  extensor  communis  digitorum  outward.  Find  the 
interosseous  membrane  where  it  is  attached  to  the  edge  of 
the  tibia,  and  the  artery  will  be  found  upon  this  membrane, 
between  the  tibia  and  the  nerve.  Clear  the  vessel  and  pass 
the  ligature  from  without  inward  to  avoid  the  nerve. 

Posterior  Tibial  Artery. — The  line  of  the  posterior 
tibial  is  from  the  middle  of  the  popliteal  space  to  a  point 
midway  between  the  tip  of  the  inner  malleolus  and  the  point 
of  the  heel  (PI.  5,  Figs.  5,  6). 

Anatomy. — The  posterior  tibial  is  the  larger  of  the  two 
terminal  branches  of  the  popliteal.  It  arises  opposite  the 
lower  border  of  the  popliteus  muscle,  passes  down  between 
the  deep  and  superficial  flexor  muscles  to  midw^ay  between 
the  tip  of  the  malleolus  and  the  point  of  the  heel,  and 
di\-ides  into  the  external  and  internal  plantar  vessels.  In  the 
upper  third  of  its  course  it  is  v&xy  deeph'  placed  midway 
between  the  tibia  and  fibula ;  in  its  middle  third  it  is  less  deep, 
having  passed  inw^ard;  and  in  its  lower  third  it  is  superficial. 
At  the  ankle  the  arter}'  is  beneath  the  annular  ligament. 
From  above  downward  the  posterior  tibial  artery  rests  upon 
the  posterior  tibial  muscle,  the  flexor  longus  digitorum  mus- 
cle, the  posterior  surface  of  the  tibia,  and  the  internal  lateral 


380   DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

ligament  of  the  ankle-joint.  For  the  first  inch  or  two  of  the 
course  of  the  artery  the  posterior  tibial  nerve  is  to  the  inner 
side ;  the  nerve  then  crosses  to  the  outer  side,  and  remains 
in  that  relative  position  throughout  the  rest  of  the  course  of 
the  artery.  When  the  knee  is  partly  flexed  and  the  leg  is 
laid  upon  its  outer  surface  the  artery  is  between  the  operator 
and  the  nerve,  and  the  nerve  is  between  the  artery  and  the 
table.  Back  of  the  malleolus,  in  the  first  compartment,  lies 
the  posterior-tibial  muscle;  in  the  next  compartment  is  the 
flexor  longus  digitorum  muscle ;  in  the  next  are  the  artery 
and  nerve ;  and  in  the  most  posterior  is  the  flexor  longus 
pollicis  muscle. 

Operations. — Ligation  Back  of  the  Mallcohts. — In  this 
operation  the  patient  is  placed  recumbent  with  the  thigh 
abducted  and  the  leg  flexed  and  resting  upon  its  outer 
surface.  The  surgeon  stands  to  the  outer  side.  Make  a  two- 
inch  semilunar  incision  corresponding  in  its  curve  to  the 
malleolus  and  half  an  inch  posterior  to  its  margin.  Cut 
down  to  the  annular  ligament,  incise  the  ligament,  and  find 
the  artery  and  venae  comites.  Clear  the  vessel  and  pass 
the  needle  from  behind  forward  (to  avoid  the  nerve,  which 
is  here  posterior  and  external).  Do  not  make  the  prelimi- 
nary incision  nearer  the  malleolus  than  half  an  inch,  as  the 
sheath  of  the  tibialis  posticus  muscle  will  then  surely  be 
opened.  In  closing  the  wound,  suture  the  ligament  by 
buried  sutures  of  catgut  before  closing  the  superficial  parts 
(PL  5,  Fig.  6). 

Ligation  in  the  Middle  of  the  Leg. — In  this  operation  the 
patient  is  placed  in  the  same  position  as  for  the  ligation 
back  of  the  malleolus.  Feel  for  the  inner  border  of  the  tibia, 
and  make  an  incision  four  inches  long  one  inch  behind  the 
osseous  border,  parallel  with  it,  and  extending  through  skin 
and  superficial  and  deep  fascia.  Draw  the  gastrocnemius 
muscle  outward.  Incise  the  soleus  muscle,  but  not  the  fascia 
beneath  the  soleus ;  cut  this  fascia,  after  dropping  the  handle 
of  the  knife  so  that  the  blade  is  at  right  angles  with  the 
plane  of  the  tibia.  Clear  the  artery;  pass  the  needle  from 
without  inward  (PI.  5,  Fig.  6). 

The  popliteal  artery  is  almost  never  ligated  in  con- 
tinuity. It  can  be  tied  at  the  upper  portion  of  the  popliteal 
space,  at  the  lower  portion  of  the  popliteal  space,  or  at  the 
inner  side  of  the  thigh. 

Anatomy  (Fig.  105). — The  popliteal  artery  is  the  contin- 
uation of  the  femoral,  and  runs  from  the  opening  in  the 
adductor  magnus  muscle  to  the  lower  margin  of  the  pop- 


POPLITEAL   AK  'PER  Y. 


381 


liteus  muscle.  This  vessel  runs  downward  and  outward 
behind  the  knee-joint  and  in  the  popliteal  space.  The  ham, 
or  popliteal  space,  is  a  lozenge-shaped  space,  which  above 
the  joint  is  bounded  on  the  outer  side  by  the  biceps  muscle, 
and  on  the  inner  side  by  the  semitendinosus,  semimembran- 
osus, gracilis,  and  sartorius  muscles,  while  below  the  jouit 
it  is  bounded  externally  by  the  plantaris  and  outer  head  of 
the  gastrocnemius  muscles,  and  internally  by  the  inner  head 
of  the  o-astrocnemius  muscle.  The  floor  of  this  space  is 
formed  by  the  surface  of  the  femur,  the  posterior  ligament 
of  the  knee-joint,  the  end  of  the  tibia,  and  the  popliteus 


Fig.  105. 


-Anatomy  of  popliteal  artery  (Bernard 
and  Huette). 


Fig.  106.— Ligation  of  popliteal  artery  in 
its  upper  third  (Bernard  and  Huette.) 


fascia  The  internal  popliteal  nerve  passes  down  the  middle 
of  the  popliteal  space;  it  is  superficial  to  the  vessels  m  the 
upper  half  of  the  space,  and  external  to  them ;  it  is  interna 
to  the  vessels  in  the  lower  half  of  the  space.  The  external 
popliteal  nerve  is  in  the  outer  side  of  the  space.  The  pop- 
liteal vein  is  between  the  nerve  and  the  artery.  Above  the 
knee-ioint  it  is  to  the  outer  side  of  the  artery,  but  below  the 
knee-joint  it  is  to  the  inner  side.     The  artery  lies  deeply  in 

the  space.  .  ^, 

Licration  in  Upper  Third .—YX^^ce  the  patient  prone,  ihe 
surcreon  stands  to  the  outer  side  of  the  limb  and  makes  a  ver- 
ticat  incision  three  inches  in  length  along  the  outer  margm 


382    DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

of  the  semimembranosus  muscle,  exposes  the  popHteal  nerve, 
retracts  the  muscle  inward  and  the  nerve  outward,  exposes 
the  artery,  separates  it  from  the  other  structures,  and  passes 
the  needle  from  without  inward  (Fig.  106). 

Ligation  in  Loiver  TJiird. — Make  a  three-inch  vertical  inci- 
sion between  the  heads  of  the  gastrocnemius  muscle.  Avoid 
the  external  saphenous  vein  and  nerve,  and  retract  them 
with  the  popliteal  nerve.  Separate  the  artery  from  the  vein 
and  pass  the  needle  from  within  outward. 

Femoral  Artery. — The  line  of  the  femoral  artery  is  from 
midway  between  the  anterior  superior  spine  of  the  ilium  and 
the  symphysis  pubis  to  the  adductor  tubercle  on  the  inner 
condyle  of  the  femur,  the  thigh  being  abducted  and  resting 
upon  its  outer  surface  (PI.  5,  Fig.  3). 

Anatomy. — The  femoral  artery  is  the  continuation  of  the 
external  iliac  trunk;  it  extends  from  the  lower  border  of 
Poupart's  ligament  to  the  opening  in  che  adductor  magnus 
muscle,  and  hence  occupies  the  upper  two-thirds  of  the 
thigh.  The  artery  for  its  first  five  inches  is  superficial,  lying 
in  Scarpa's  triangle,  a  space  which  is  bounded  externally  by 
the  sartorius  muscle  and  internally  by  the  adductor  longus, 
its  base  being  Poupart's  ligament  and  its  floor  being  com- 
posed of  the  psoas,  iliacus,  pectineus,  and  adductor  longus 
muscles,  and  often  the  adductor  brevis.  The  artery  enters 
the  triangle  as  the  common  femoral,  but  after  a  two-inch 
course  it  divides  into  the  profunda  (which  passes  deeply) 
and  the  superficial  femoral.  The  latter  vessel  is  the  one 
alluded  to  in  this  section. 

At  the  base  of  Scarpa's  triangle  the  vein  is  internal,  the 
artery  is  between,  and  the  nerve  is  external  (v.  a.  n.)  At 
the  apex  of  the  triangle  the  vein  is  internal  and  a  little  pos- 
terior. At  the  apex  of  the  triangle  the  superficial  femoral 
passes  under  the  sartorious  muscle  and  enters  into  Hunter's 
canal,  which  occupies  the  middle  third  of  the  thigh  and 
which  terminates  at  an  opening  in  the  adductor  magnus 
muscle.  Hunter's  canal  is  bounded  externally  by  the  vastus 
internus  muscle,  internally  by  the  adductors  longus  and 
magnus,  and  its  roof  is  fascia  which  stretches  from  the 
adductor  longus  to  the  vastus  internus.  In  Hunter's  canal 
the  vein  is  behind  the  artery  in  the  upper  part,  but  external 
to  it  in  the  lower  part,  and  is  firmly  attached  to  the  artery. 
There  may  be  two  veins.  Inside  Hunter's  canal,  but  outside 
the  femoral  sheath,  is  the  long  saphenous  nerve,  which 
crosses  the  artery  from  without  inward. 

A  way  to  remember  the  jrelation  of  the^Jemoral  vein_Jto 


FEMORA  L   A  R  TER  Y.  383 

the  femoral  artery  is  to  recall  the  fact  that  the  relation  of 
the  vein  to  the  artery  is  always  contrary  to  the  relation  of 
the  sartorius  muscle  to  the  artery:  when  the  sartorius  mus- 
cle is  external  to  the  artery  the  vein  is  internal,  as  at  the 
base  of  Scarpa's  triangle ;  when  the  sartorius  muscle  is  cross- 
ing in  front  toward  the  inside  of  the  artery,  the  vein  is  pass- 
ing at  the  back  to  the  outside,  as  at  the  apex  of  Scarpa's 
triangle;  when  the  muscle  is  over  the  artery  the  vein  is  back 
of  it,\s'in  the  upper  third  of  Hunter's  canal;  and  when  the 
muscle  is  to  the  inside  of  the  artery  the  vein  is  to  the  out- 
side, as  in  the  lower  two-thirds  of  Hunter's  canal.  In  a 
ligation  at  the  apex  of  Scarpa's  triangle  the  inner  edge  of 
the  sartorius  is  the  guide.  In  a  ligation  in  Hunter's  canal 
the  long  saphenous  nerve  is  the  guide. 

Operations. — Ligation  of  the  Superficial  Femoral  at  the 
Apex  of  Scarpa's  Triangle. — In  this  operation  the  position  of 
the  patient  is  supine  with  the  thigh  and  leg  partly  flexed,  and 
the  thigh  abducted,  everted,  and  rested  upon  its  outer  surface 
on  a  pillow.  The  operator  stands  to  the  outer  side  of  the 
extremity.  From  a  point  corresponding  to  the  middle  of 
Scarpa's  triangle,  and  two  and  a  half  inches  below  Poupart's 
ligament,  make  a  three-inch  incision  in  the  arterial  line. 
Cut  the  skin  and  superficial  fascia.  The  saphenous  vein 
will  .not  be  seen  unless  the  incision  is  internal  to  the 
arterial  line ;  if  this  vein  is  seen,  draw  it  inward.  Open 
the  fascia  lata,  find  the  inner  border  of  the  sartorius  mus- 
cle, and  draw  it  outward.  The  fibers  of  this  muscle  run 
downward  and  inward,  thus  distinguishing  it  from  the  ad- 
ductor longus,  whose  fibers  run  downward  and  outward. 
Open  the  common  sheath  for  the  artery  and  vein,  and  then 
incise  the  individual  arterial  sheath.  Clear  the  artery  and 
pass  the  ligature  from  within  outward  (PI.  5,  Fig.  4). 

Ligation  of  the  Superficial  Femoral  in  Hunter's  Canal. — In 
this  operation  the  position  of  the  patient  is  the  same  as  in 
the  ligation  at  the  apex  of  Scarpa's  triangle.  Make  a  three- 
inch  incision  in  the  middle  third  of,  but  above  the  middle 
of,  the  thigh,  parallel  with  the  arterial  hne  and  half  an  inch 
internal  to  it  (Barker).  Incise  the  skin  and  superficial  fascia, 
look  out  for  the  internal  saphenous  vein,  open  the  fascia 
lata,  find  the  sartorius  muscle,  and  retract  it  inward,  thus 
exposing  the  roof  of  Hunter's  canal,  which  is  to  be  opened 
for  an  inch  or  more.  Within  the  canal  is  seen  the  long 
saphenous  nerve,  usually  upon  the  sheath.  Open  the  sheath 
of  the  artery,  clear  the  vessel,  and  pass  the  needle  from  with- 
out inward. 


384   DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

Iliac  Arteries. — The  line  of  the  common  and  external 
ihac  artery  is  from  a  point  half  an  inch  below  and  half  an 
inch  to  the  left  of  the  umbilicus  to  midway  between  the 
anterior  superior  spine  of  the  ilium  and  the  pubic  sym- 
physis. The  upper  third  of  this  line  represents  the  common 
iliac,  and  the  lower  two-thirds  the  external  iliac  (PI.  2,  Fig.  4). 

Anatomy. — The  common  iliac  arteries  arise  from  the  aorta 
opposite  the  left  side  and  lower  border  of  the  fourth  lumbar 
vertebra,  and  extend  to  the  upper  margin  of  the  right  and 
left  sacroiliac  joints,  where  they  each  bifurcate  into  an  exter- 
nal and  an  internal  ihac.  The  common  iliac  arteries  lie  upon 
the  fifth  lumbar  vertebra,  are  covered  with  peritoneum,  and 
are  crossed  by  the  ureters.  In  women  the  ovarian  arteries 
cross  the  common  iliacs.  Each  common  iliac  vein  lies  to 
the  right  side  of  its  associated  artery.  The  right  common 
iliac  artery  has  in  front  of  it,  besides  the  peritoneum  and 
ureter  (in  women  also  the  ovarian  artery),  the  ileum,  branches 
of  the  superior  mesenteric  artery,  and  branches  of  the  sym- 
pathetic nerve.  The  left  common  iliac  artery  has  in  front 
of  it,  in  addition  to  structures  common  to  both  sides  (ureter, 
ovarian  artery,  sympathetic  branches),  branches  of  the  infe- 
rior mesenteric  artery  and  the  sigmoid  flexure  with  its  meso- 
colon. The  internal  iliac  artery  runs  from  the  sacroiliac  joint 
to  the  upper  margin  of  the  great  sacrosciatic  foramen.  It  is 
very  rarely  ligated  (only  for  gluteal  aneurysm,  for  uncon- 
trollable hemorrhage  from  the  gluteal  or  sciatic  arteries,  or 
to  produce  atrophy  of  the  prostate  gland).  The  external 
iliac  artery  runs  from  the  sacroiliac  joint  along  the  pelvic 
brim,  upon  the  inner  edge  of  the  psoas  muscle,  to  Poupart's 
ligament.  The  external  iliac  vein  is  internal  to  the  artery. 
On  the  right  side,  high  up,  it  passes  behind  the  artery.  The 
external  iliac  artery  has  in  front  of  it  peritoneum  and  sub- 
serous tissue  (Abernethy's  fascia).  The  ileum  crosses  the 
right,  and  the  sigmoid  flexure  crosses  the  left,  external  iliac 
artery.  The  genital  branch  of  the  genitocrural  nerve  crosses 
the  artery  low  down,  and  the  circumflex  iliac  vein  crosses  it 
just  before  it  terminates  in  the  femoral.  The  spermatic  ves- 
sels and  the  vas  deferens  in  the  male,  and  the  ovarian  vessels 
in  the  female,  lie  upon  the  artery  near  its  termination. 
Sometimes  the  ureter  crosses  the  vessel  near  its  point  of 
origin.  The  spermatic  vessels  in  the  male  and  the  ovarian 
vessels  for  a  part  of  their  course  in  the  female  rest  upon  the 
inner  side  of  the  artery. 

Ligation  of  the  Iliac  Arteries  after  Abdominal  Section. — 
The  best  method  for  ligating  the  common,  the  external,  or  the 


GLUTEAL   ARTERY.  385 

internal  iliac  is  by  abdominal  section.  The  patient  is  placed 
in  the  Trendelenburg  position.  The  abdomen  is  opened 
in  the  midline  below  the  umbilicus.  The  intestines  are 
lifted  toward  the  diaphragm,  and  are  held  up  by  gauze 
pads.  The  edges  of  the  incision  are  retracted.  The  vessel 
to  be  tied  is  located  and  the  point  for  ligation  is  selected. 
The  posterior  layer  of  the  peritoneum  is  opened  over  the 
selected  point,  the  vessel  is  cleared,  and  the  threaded 
Dupuytren's  aneurysm-needle  is  passed  in  a  direction  away 
from  the  vein.  In  ligating  either  common  iliac,  pass  the  nee- 
dle from  right  to  left.  In  ligating  the  external  iliac,  pass 
the  ligature  from  within  outward.  In  ligating  the  internal 
iliac,  pass  the  needle  from  within  outward.  It  is  not  neces- 
sary to  suture  the  posterior  layer  of  peritoneum.  The  abdo- 
men is  closed  without  a  drain.  In  these  operations  be  sure 
to  push  the  ureter  out  of  the  way.  This  method  of  oper- 
ating is  endorsed  by  Dennis,  Hearn,  Marmaduke  Shield, 
Mitchell  Banks,  and  others  who  have  employed  it. 

Ligation  of  the  External  Iliac  by  Abernethf  s  Extraperito- 
neal Method  (PI.  2,  Fig.  4). — The  patient  is  placed  recum- 
bent with  the  thighs  extended  during  the  first  incisions ;  but 
in  the  later  stages  of  the  operation  the  thighs  are  flexed  a 
little,  to  relax  the  abdominal  structures.  The  operator  stands 
to  the  outer  side.  The  surgeon  will  find  the  artery  by  the  side 
of  the  psoas  muscle.  Mark  a  point  one  inch  above  and  one 
inch  external  to  the  middle  of  Poupart's  ligament,  and  another 
point  one  inch  above  and  one  inch  internal  to  the  anterior 
superior  iliac  spine  (Barker).  Join  these  two  points  by  a 
curved  incision  four  inches  long  and  convex  downward. 
Cut  the  skin,  the  fat,  the  two  oblique,  and  the  transversalis 
muscles ;  open  the  transversalis  fascia,  separate  the  perito- 
neum toward  the  vessels,  and  draw  it  inward  by  a  broad 
retractor,  and  look  for  the  artery  along  the  pelvic  brim.  The 
anterior  crural  nerve  is  seen  to  the  outer  side  of  the  artery, 
the  external  iliac  vein  is  to  the  inner  side  of  the  artery,  and 
the  genitocrural  nerve  is  upon  the  artery.  Clear  the  artery 
near  its  middle  and  pass  the  ligature  from  within  outward. 
In  Sir  Astley  Cooper's  method  of  ligation  the  inguinal  canal 
is  opened ;  in  Abernethy's  method  the  inguinal  canal  is  not 
opened. 

The  Gluteal  Artery. — This  vessel  is  a  continuation  of 
the  posterior  division  of  the  internal  iliac.  It  emerges  from 
the  great  sacrosciatic  foramen  at  the  upper  border  of  the 
pyriformis  muscle.  It  rests  upon  the  glutaeus  minimus 
muscle,  divides  into  three  branches,  and  is  covered  by  the 
25 


386   DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

glutseus  maximus  muscle.     The  superior  gluteal  nerve  lies 
inferior  to  the  artery  (Fig.  107). 

Ligation.— The   patient    should   be  prone.     The  surgeon 
stands  to  the  outer  side.     The  incision  corresponds  to  a  Une 


Fig.  107. — A,  Nephrotomy  ;  a,  last  dorsal  n. ;  b,  latissimus  dorsi  m.  ;  c,  serratus  post,  in- 
ferior m.  ;  d,  m'iddle  layer  of  lumbar  fascia  ;  e,  outer  layer  ;  /.  ext.  oblique  m. ;  g,  int.  oblique 
m.  •  //,  p'erinephritic  (extraperitoneal)  fat ;  ?,  quadratus  lumborum  m.  ;  y,  erector  spinae  m. 
B  Nephrotomy  :  a,  first  lumbar  n. ;  b,  kidney ;  c,  transversalis  fascia.  C,  Ligature  of  the 
sciatic  and  internal  pudic  arteries,  and  exposure  of  the  great  sciatic,  sinall  sciatic,  and  inter- 
nal pudic  nerves  :  a,  gluteus  maximus  m.  ;  b,  inf.  gluteal  n. ;  c,  sciatic  a ;  d,  int.  pudic  a. 
and  n.  •  e,  great  sciatic  n. ;  /,  small  sciatic  n. ;  g,  pyriforrais  m.  D,  Ligature  of  the  gluteal 
artery  and  exposure  of  the  superior  gluteal  nerve  :  a,  glutaeus  maximus  m.  ;  b,  gluteal  a.  ;  c, 
superior  gluteal  n. ;    rf,  pyriformis  m.  ;<?,  glutaeus  medius  m.     (Kocher.) 

drawn  from  the  posterior  superior  iliac  spine  to  the  upper 
border  of  the  great  trochanter.  Divide  the  skin,  fascia, 
glutaeus  maximus  muscle,  and  the  fascia  over  the  glutaeus 
medius  muscle,  and  retract  the  glutaeus  medius  upward.  Feel 
for  the  great  sacrosciatic  foramen,  and  at  this  point  the  artery 


LIGATION  OF  THE  ABDOMINAL   AORTA.  387 

is  found  above  the  pyriformis  muscle.  Clear  the  vessel  and 
pass  the  needle  from  below  upward  (see  Kocher's  Operative 
Surge)-)'). 

The  Sciatic  Artery. — This  artery  is  the  larger  of  the 
terminal  branches  of  the  anterior  division  of  the  internal  iliac 
artery.  It  passes  to  the  lower  portion  of  the  great  sacrosci- 
atic  foramen,  lying  back  of  the  internal  pudic  artery,  and  rest- 
ing upon  the  sacral  plexus  of  nerves  and  pyriformis  muscle 
(Gray).  It  leaves  the  pelvis  between  the  pyriformis  and  coc- 
cygeus  muscles,  and  passes  downward  between  the  ischial 
tuberosity  and  great  trochanter.  It  is  covered  by  the  glutaeus 
maximus  muscle,  rests  upon  the  gemelli,  internal  obturator 
and  quadratus  femoris  muscles,  has  the  great  sciatic  nerve 
external  to  it,  and  the  small  sciatic  nerve  external  and  pos- 
terior (Fig.  107). 

Ligation. — The  patient  lies  prone.  The  surgeon  stands  to 
the  outer  side.  The  incision  "  corresponds  to  the  middle 
two-thirds  of  a  line  extending  from  the  posterior  inferior 
iliac  spine  to  the  base  of  the  great  trochanter."  ^  Divide  the 
skin,  fat,  fascia,  and  the  glutaeus  maximus  muscle.  Find  the 
artery  at  the  lower  border  of  the  pyriformis  muscle  and  trace 
it  to  its  point  of  emergence  from  the  pelvis.  Pass  the  liga- 
ture from  without  inward. 

Internal  Pudic  Artery. — This  artery  is  one  of  the  ter- 
minal branches  of  the  anterior  trunk  of  the  internal  iliac. 
It  passes  to  the  lower  margin  of  the  great  sacrosciatic  fora- 
men, and  leaves  the  pelvis  between  the  pyriformis  and  coc- 
cygeus  muscles,  crosses  the  ischial  spine,  and  again  enters 
the  pelvis  by  the  lesser  sacrosciatic  foramen.  The  vessel  is 
accompanied  b)'  the  internal  pudic  nerve  (Fig.  107). 

Ligation. — The  position  of  the  patient  and  the  incision  are 
the  same  as  for  ligation  of  the  sciatic  arter^^  The  arteiy  is 
found  below  the  ischial  spine.  Pass  the  needle  from  below 
upward  to  avoid  the  nerve. 

I/igation  of  the  Abdominal  Aorta. — This  operation 
was  first  performed  by  Sir  Astley  Cooper  in  18 17.  The 
patient  lived  but  a  few  hours.  Eleven  cases  of  ligation  of 
the  aorta  have  been  published,  and  there  were  eleven  deaths. 
The  patient  of  IMonteiro  of  Rio  Janeiro  lived  for  ten  days. 
The  circulation  was  entirely  restored  in  the  limbs,  and  the 
man  died  from  hemorrhage  resulting  from  the  ulceration 
produced  by  a  septic  ligature.  This  case  proves  that  under 
certain  circumstances  the  operation  is  feasible,  and  in  desperate 
cases  it  must  be  considered  as  a  possible  means  of  treatment. 

^  Kocher's  Operative  Surgery,  by  Stiles. 


388   DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS. 

I  lately  assisted  Prof.  Keen  in  a  remarkable  case,  in  which 
the  aorta  was  ligated  above  the  renals  for  aneurysm.  The 
man  lived  seven  weeks.  The  circulation  in  the  legs  was 
restored  in  twenty-four  hours.  Urinary  secretion  continued. 
Death  was  due  to  the  ligature  cutting  completely  through 
the  aorta. 

Murray's  operation  aims  to  avoid  opening  the  peritoneum. 
An  incision  is  made  from  just  below  the  tip  of  the  tenth 
rib  to  a  point  one  inch  internal  to  the  anterior  superior  iliac 
spine.  The  peritoneum  is  separated  from  the  abdominal  wall 
until  the  vessel  is  reached.  Cooper's  operation  by  abdominal 
section  is  the  preferable  procedure. 

Operation  by  Abdominal  Section  {^Cooper s  Operation). — 
Instruments  Required. — Those  used  in  any  ligation,  with 
the  addition  of  an  aneurysm-needle  with  a  large  curve 
and  a  very  long  handle.  With  an  ordinary  instrument  it  is 
extremely  difficult  to  pass  the  ligature.  It  would  be  a  great 
advantage  to  use  an  instrument  which,  after  being  passed 
under  the  vessel,  could  have  a  central  eyed  shaft  projected, 
as  is  the  center  shaft  of  a  Bellocq  cannula.  Floss  silk  is 
probably  the  best  ligature-material. 

If  the  patient  is  much  exhausted,  an  assistant  should  infuse 
salt  solution  in  a  vein  during  the  operation.  In  Keen's  case 
there  was  profound  shock,  but  the  moment  the  ligature  was 
tightened  it  passed  away. 

Operation. — The  patient  should  be  placed  upon  his  back. 
The  surgeon  stands  to  the  right  of  the  patient  and  opens  the 
abdomen  in  the  median  line,  a  little  above  the  level  of  the 
aneurysm.  The  intestines  are  packed  aside,  the  posterior 
layer  of  the  peritoneum  is  divided,  the  surface  of  the  aorta 
over  a  small  area  is  cleared  of  nerves,  the  plexuses  being 
separated  with  a  blunt  dissector. 

The  needle  is  passed  from  right  to  left.  A  double  ligature 
of  floss  silk  should  be  passed  and  the  ends  should  be  tied 
with  a  stay-knot.     The  wound  is  closed  and  dressed. 

It  has  been  suggested,  I  think  by  Wyeth,  that  it  might  be 
wise  to  only  partially  tighten  the  ligature  at  first,  completing 
the  occlusion  of  the  artery  after  a  day  or  two.  Such  a  pro- 
cedure would  certainly  give  a  better  chance  for  the  collaterals 
to  dilate,  and  restore  circulation  in  the  legs. 

Unfortunately,  in  an  aneurysm,  the  vessel  will  usually  be 
extensively  diseased,  and  ligation  will  be  out  of  the  question. 
If,  however,  a  normal  region  is  found,  the  chance  of  success 
in  a  case  of  aneurysm  will  be  greater  than  in  a  case  of  hemor- 
rhage from  a  branch  of  the  aorta,  because,  in  a  case  of  aneu- 


OSTEITIS,    PERIOSTITIS,    AND    OSTEOPERIOSTITIS.     389 

rysm,  the  probabilities  are  that  the  collaterals  are  somewhat 
distended  before  a  ligature  is  applied. 

XIX.    DISEASES  AND  INJURIES  OF  BONES  AND 
JOINTS. 

I.  Diseases  of  the  Bones. 

Atrophy  of  bone  is  a  diminution  in  the  amount  of  bony 
matter  without  change  in  osseous  structure.  It  arises  from 
want  of  use  (as  seen  in  the  wastin.g  of  the  bone  of  a  stump) 
or  from  pressure  (as  seen  in  the  destruction  of  the  sternum 
by  an  aneurysm  of  the  aorta).  Eccentric  atrophy  is  the 
thinning  of  a  long  bone  from  within,  the  outer  surface 
being  unchanged.  It  is  usually  a  senile  change.  Concentric 
atrophy  means  a  thinning  of  the  outer  surface  of  the  shaft, 
causing  a  lessened  diameter.  It  is  usually  linked  with  eccen- 
tric atrophy. 

Hypertrophy  of  bone  may  be  due  to  increased  blood- 
supply  (as  is  seen  in  chronic  epiphyseal  inflammation),  the 
bone  growing  much  more  than  does  its  fellow.  It  may  arise 
from  excessive  use  or  from  strain,  as  is  seen  in  the  increased 
size  of  the  fibula  when  the  tibia  is  congenitally  absent 
(Bowlby). 

Tumors  of  Bone. — Bones  give  origin  to  both  innocent 
and  malignant  tumors.  Myeloid  sarcoma  takes  origin  in 
the  endosteum  and  expands  the  bone.  The  fasciculated 
sarcoma  is  a  periosteal  growth.  Besides  these  growths  there 
are  osteomata,  chondromata,  and  secondary  deposits  of  can- 
cer and  sarcoma.  There  is  no  such  thing  as  primary  cancer 
of  bone.  A  bone  may  become  cystic,  and  occasionally  the 
cysts  are  due  to  hydatids.     Gummata  are  frequently  met  with. 

Actinomycosis  of  bone  is  most  usual  in  the  jaw,  but 
may  attack  the  orbit,  ribs,  sternum,  or  limbs  (see  p.  235). 

Tuberculosis  of  bone  tends  especially  to  appear  in 
the  cancellous  ends  of  long  bones.  Is  apt  to  caseate  and 
destroy  large  amounts  of  bone.  The  bone  does  not  sclerose, 
but  undergoes  alterations  of  an  osteoporotic  nature  (see  p. 
196). 

Osteitis,  Periostitis,  and  Osteoperiostitis. — Ostei- 
tis, or  inflammation  of  bone,  may  be  due  to  traumatism, 
to  a  constitutional  malady  or  diathesis,  to  the  extension  of 
inflammation  from  some  other  structure,  or  to  infection.  In 
inflammation  of  bone  the  exudate  and  leukocytes  pass  into 
the  Haversian  canals  and  spaces  and  the  canaliculi,  and  the 
cells  of  the  exudate  and  the  bone-corpuscles  proliferate,  the 


390    DISEASES  AND  INJURIES   OF  ^ONES  AND  JOINTS. 

bone  undergoing  thinning  (rarefaction),  not  because  of 
pressure,  but  because  of  absorption  by  voracious  leukocytes 
and  osteoclasts.  This  process  of  rarefaction  enlarges  all  the 
bony  spaces,  and  by  destroying  septa  throws  many  of  the 
spaces  into  one.  If  the  surface  of  a  bone  inflames,  the  peri- 
osteum will  be  separated  more  or  less  by  the  exudation,  and 
the  bone  will  be  covered  with  little  pits  or  erosions  made  by 
the  leukocytes.  Inflamed  bone  is  so  soft  that  it  can  readily 
be  cut  with  a  knife. 

Osteitis  may  terminate  in  resohttioii  or  it  may  terminate  in 
sclerosis,  the  exudate  being  converted  first  into  fibrous  tissue 
and  next  into  dense  bone  with  only  a  few  small  cancellous 
spaces.  If  the  exudation  is  under  the  periosteum,  the  bone 
will  be  thickened  at  this  point,  bone  stalactites  marking  the 
points  of  passage  of  the  vessels.  Osteitis  may  terminate  in 
suppuration,  this  condition  being  often  called  '^  caries."  In 
tubercular  osteitis  caseation  of  the  inflammatory  products  is 
very  apt  to  arise  (tubercular  or  strumous  caries).  Acute 
osteitis  may  terminate  in  necrosis,  the  inflammatory  exudate 
compressing  the  vessels  in  their  bony  canals,  a  portion  of 
the  bone  being  in  consequence  deprived  of  nutritive  material. 
The  portion  cut  off  from  nutritive  fluid  dies  en  masse  (necro- 
sis). Osteitis  is  usually  associated  with  more  or  less  perios- 
titis. A  simple  acute  periostitis  without  involvement  of  the 
bone  may  arise  from  traumatism  or  strain ;  but  in  all  severe 
cases  of  periostitis,  in  all  chronic  cases,  in  all  cases  due  to 
syphilis,  rheumatism,  measles,  scarlatina,  or  enteric  fever  the 
bone  is  involved  at  the  same  time  or  subsequently.  In  syph- 
ilitic states  gummatous  degeneration  frequently  ensues. 

Symptoms  of  Osteitis  and  Osteoperiostitis. — As  a 
chronic  process  osteitis  is  most  commonly  found  in  the 
femur.  Its  history  usually  exhibits  a  record  of  an  antecedent 
injury  or  chilling  of  the  body.  Pain  is  severe,  boring  or 
aching  in  character,  deep-seated,  worse  at  night,  and  aggra- 
vated by  a  dependent  position  of  the  part.  The  symptoms 
closely  resemble  those  of  periostitis,  with  which  disease  it  is 
almost  sure  to  be  linked.  Tenderness  exists  on  percussion, 
and  sometimes  on  pressure.  Subperiosteal  swelling,  fusiform 
in  shape,  is  noted ;  cutaneous  edema  and  discoloration  are 
observed  if  a  superficial  bone  is  inflamed.  In  syphilis, 
atrophic  osteitis  may  attack  the  cranial  bones  and  produce 
softening  or  even  perforation,  or  osteophytic  osteitis  may  arise, 
exostoses  being  formed.  Osteoperiostitis  may  be  acute  or 
chronic,  circumscribed,  or  diffused,  and  may  terminate  in 
resolution,  organization,  or  suppuration.     It  arises  from  cold, 


OSTEITIS,    PERIOSTITIS,   AXD    OSTEOPERIOSTITIS.    39 1 

blows,  wounds,  strains,  the  spread  of  adjacent  inflammation, 
specific  febrile  maladies,  pyogenic  infection,  syphilis,  rheuma- 
tism, or  tuberculosis.  The  symptoms  are  pain  (which  is 
worse  at  night  and  which  is  aggravated  by  motion,  press- 
ure, or  a  dependent  position),  swelling,  edema,  and  dis- 
coloration of  the  soft  parts.  Pain  in  the  syphilitic  form  is 
not  so  severe  as  in  other  \'arieties.  Acute  necrosis  or  diffuse 
periostitis,  a  septic  inflammation  of  bone  and  periosteum, 
is  commonest  in  bo}'s  about  the  age  of  puberty.  It  is 
usually  due  to  cold,  a  specific  fever,  or  injury,  and  most  often 
affects  the  tibia  or  femur ;  the  symptoms  locally  are  redness, 
swelling,  and  severe  pain ;  constitutionally  there  are  rigors, 
fever,  and  sometimes  convulsions.  Necrosis  is  apt  to  result. 
Pyemia  is  common.  In  simple  acjtte  periostitis  a  swelling  is 
felt  upon  the  osseous  surface.  The  swelling  is  firmly  fixed 
and  is  very  tender,  but  the  bone  itself  is  not  enlarged.  There 
is  some  local  heat,  discoloration,  often  fever,  and  the  patient 
complains  of  an  aching  pain,  which  is  worse  at  night. 

Periostitis  due  to  strain  demands  some  special  attention. 
Sir  James  Paget,  years  ago,  pointed  out  that  muscular  exer- 
tion might  cause  periostitis.  C.  T.  Dent  has  written  a  valu- 
able article  upon  this  subject.^ 

It  is  common  to  hear  football-players  complain  of  some 
swelling  of  the  knee-joint.  Examination  finds  tenderness 
over  the  tubercle  of  the  tibia  with  slight  swelling  of  the  joint. 
Dent  points  out  that  pain  is  felt  on  straightening  the  leg, 
not  on  rotating  it.  The  same  observer  states  that  omnibus- 
drivers  suffer  from  periostitis  of  the  fibula,  due  to  pressing 
forcibly  against  the  foot-board  ;  those  who  ride  may  develop 
periostitis  of  the  adductor  insertion  (riders'  bone) ;  the  vic- 
tims of  flat-foot  may  labor  under  periostitis  of  the  inner 
tuberosity  of  the  os  calcis ;  bar-keepers,  from  working  a 
beer-pump,  may  get  periostitis  of  the  scapula,  pain  being 
marked  on  contracting  the  biceps  ;  a  housemaid  may  de- 
velop periostitis  at  the  points  of  bony  origin  of  the  great 
pectoral  from  the  chest,  the  condition  being  due  to  sweeping 
and  scrubbing.^ 

Treatment  of  Osteitis  and  Osteoperiostitis. — In  s}'philitic 
forms  the  local  treatment  consists  of  rest,  ele\'ation  of  the  part, 
the  application  of  iodin  and  mercurial  ointment,  and  band- 
aging. Specific  treatment  is  by  the  stomach  or  hypoderm- 
atically.  Operation  is  rarely  justifiable.  In  other  forms,  if 
the  case  be  recent  and  severe,  put  the  patient  to  bed,  place 
the  limb  in  a  splint  and  elevate  it,  apply  leeches,  employ  cold, 

^  Practitioner,  October,  1897.  *  Ibid. 


392    DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS. 

apply  a  bandage,  and  give  salines  and  iodid  of  potassium 
internally.  Later  use  ichthyol  inunctions  locally  and  apply 
a  hot  water-bag.  Morphin  is  administered  for  pain.  If  these 
means  fail,  order  counterirritation  by  iodin  and  blue  oint- 
ment or  blisters,  and  apply  heat  locally.  In  severe  cases  take 
a  tenotome  and  slit  the  periosteum  subcutaneously  to  relieve 
tension ;  this  procedure  often  quickly  relieves  the  pain. 
Some  cases  demand  a  longitudinal  osteotomy,  which  is  per- 
formed by  taking  Hey's  saw  and  dividing  the  bone  longi- 
tudinally into  the  medullary  canal.  If  pus  forms,  drain  at 
once. 

Diffiise  osteopcTiostitis  requires  early  and  free  incisions, 
antiseptic  irrigation,  drainage,  rest  and  elevation  of  the  limb, 
and  strong  supporting  and  stimulating  treatment.  Ampu- 
tation is  sometimes  demanded,  as  when  the  patient  grows 
weaker  and  weaker  even  after  incision,  and  when  a  joint  is 
seriously  involved.  If  the  necrosis  affects  the  entire  shaft, 
which  separates  from  its  epiphyses,  and  new  bone  has  not 
yet  formed  from  the  periosteum,  make  a  subperiosteal  resec- 
tion of  the  shaft. 

Chronic  periostitis  is  usually  syphilitic.  A  node  is  a 
chronic  inflammation  of  the  deep  periosteal  layers.  Nodes 
occurring  early  in  the  secondary  stage  remain  soft  and  soon 
pass  away  under  treatment,  but  those  occurring  two  years 
or  more  after  infection  are  apt  to  cause  a  bony  deposit.  A 
node  may  soften,  leaving  a  sinus,  at  the  bottom  of  which  is  a 
piece  of  dead  bone.  Gumma  of  the  periosteum  is  one  form 
of  node  which  is  apt  to  produce  caries  or  necrosis. 

Osteoplastic  periostitis  accompanies  chronic  osteitis  and 
causes  the  deposit  of  new  bone,  which  undergoes  sclerosis. 
The  chief  symptom  is  aching  pain,  which  is  worse  wherr 
the  patient  is  warm  in  bed,  and  is  aggravated  by  damp  and 
wet.  A  swelling  is  found  at  the  seat  of  pain  (often  over 
the  tibia,  ulna,  clavicle,  or  sternum).  The  soft  parts  are 
uninflamed  and  move  freely  unless  softening  or  suppuration 
has  occurred.     Tenderness  is  manifest. 

Treatment  of  Clironic  Periostitis  and  Osteoplastic  Periostitis. 
— For  the  nodes  of  early  syphilis  use  mercurial  treatment ; 
for  the  nodes  of  late  syphilis  give  mercury  and  large 
advancing  doses  of  iodid  of  potassium.  Blisters,  blue  oint- 
ment, and  iodin  are  used  locally,  and  subcutaneous  division 
of  the  periosteum  is  of  value.  If  suppuration  occurs,  incise 
antiseptically. 

Abscess  of  bone  is  usually  due  to  tubercular  infection. 
It  is  always  chronic,  never  acute.     A  very  acute  inflamma- 


CARIES.  393 

tion,  such  as  is  induced  by  pyogenic  organisms,  causes 
acute  necrosis  rather  than  an  acute  abscess.  After  typhoid 
fever  an  area  of  suppuration  may  slowly  form  in  the  head  of 
a  long  bone,  due  to  the  action  of  typhoid  bacilli.  After  a 
tubercular  abscess  forms  mixed  infection  may  take  place,  the 
seat  of  abscess  being  a  point  of  least  resistance.  Chronic 
abscess  of  bone  was  first  described  by  Sir  Benjamin  Brodie, 
and  is  often  called  "  Brodie's  abscess."  It  occurs  in  the 
cancellous  structure  of  the  ends  of  bones — usually  in  the 
head  of  the  tibia,  sometimes  in  the  femur  or  humerus.  A 
tubercular  abscess  of  bone  may  follow  a  slight  injury,  induc- 
ing osteitis,  which  constitutes  a  point  of  least  resistance. 
Bacteria  lodge  and  multiply ;  bone  rarefaction  leads  to  the 
formation  of  a  cavity,  the  inflammatory  products  caseate  and 
sometimes  suppurate,  and  the  surrounding  bone  thickens 
and  hardens  because  of  growth  from  the  periosteum.  The 
abscess  is  apt  to  break  into  a  joint,  as  the  joint-surface  is  not 
covered  by  periosteum  and  no  barrier  of  bone  is  there 
formed.     Brodie's  abscess  may  induce  necrosis. 

Symptoms. — The  symptoms  are  like  those  of  osteo- 
periostitis, only  they  are  localized  and  persistent.  These 
symptoms  are  thickening  of  the  bone  and  soft  parts,  edema 
and  discoloration  of  the  skin  over  the  seat  of  trouble,  ten- 
derness, constant  pain  (subject  to  violent  exacerbations, 
worse  at  night  when  warm  in  bed,  and  made  worse  by 
motion,  pressure,  or  a  dependent  position),  and  attack  after 
attack  of  synovitis  in  the  nearest  joint.  Fever  and  sweats 
may  be  noted. 

Treatment. — In  treating  bone-abscess,  trephine  the  bone 
at  the  point  of  greatest  tenderness,  and  if  the  abscess  is 
missed,  follow  the  advice  of  Holmes  and  perforate  the  wall 
of  bone  with  the  trephine,  opening  in  several  directions  to 
discover  the  pus.  It  is  often  easy  to  open  into  the  abscess 
with  a  chisel  or  gouge.  After  opening  the  cavity  scrape  its 
walls  thoroughly,  dry  with  gauze,  touch  with  pure  carbolic 
acid,  and  pack  with  iodoform  gauze.  If  the  abscess  opens 
into  a  joint,  trephine  the  bone  and  open,  irrigate,  and  drain 
the  joint. 

Caries  was  a  term  used  formerly  to  signify  suppuration 
or  molecular  death  of  bone.  In  some  cases  caries  means 
suppurative  osteitis,  in  others,  tubercular  osteitis,  in  still 
others,  gummatous  osteitis.  Typhoid  fever  is  occasionally 
followed  by  a  carious  condition  of  bone.  Osteitis  is  apt  to 
become  purulent  when  the  bone  is  exposed  to  the  air,  when 
rest  is  not  secured,  when  the  health  of  the  individual  is  below 


394  DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

normal,  when  a  foreign  body  such  as  a  bullet  is  in  the  bone, 
or  when  tubercle  or  syphilis  exists.  The  term  is  rarely  used 
to-day  except  loosely,  and  then  usually  to  signify  tubercular 
disease  of  bone.  When  caries  arises,  the  softened  and  granu- 
lating bone  breaks  down  and  is  discharged  through  a  sinus. 
After  drainage  is  secured  organization,  sclerosis,  and  healing 
may  result.  In  these  cases  new  bone  may  form,  and  a  cure 
result. 

Tubercular  caries,  clue  to  caseation  of  the  products  of  a 
tubercular  osteitis,  shows  no  tendency  to  self-cure,  no 
organization  or  sclerosis  takes  place,  and  no  new  bone 
forms  unless  an  operation  is  performed.  The  interior  of 
bones,  especially  of  the  carpus  and  tarsus,  is  entirely  soft- 
ened and  destroyed,  and  thin  shells  only  are  left. 

Caries  necrotica  is  a  condition  in  which  small  but  visible 
portions  of  soft  and  dead  bone  are  cast  off;  caries  sicca  is 
molecular  death  of  bone  without  suppuration. 

The  caseating  masses  in  tubercular  caries  contain  the 
tubercle  bacillus.  If  a  tubercular  collection  is  evacuated 
and  infection  with  pus  organisms  occurs,  genuine  suppura- 
tion takes  place,  and  constitutional  infection  causes  septic 
fever,  and  may  cause  death.  Purulent  osteitis  may  affect 
any  part  of  any  bone ;  but  caseous  osteitis  (tubercular 
caries)  tends  to  arise  especially  in  cancellous  structures 
(heads  of  long  bones,  vertebral  bodies,  ribs  and  sternum, 
and  bones  of  the  carpus  and  tarsus).  Tubercular  osteitis 
of  the  shaft  of  a  long  bone  occasionally,  but  rarely,  arises. 
Tubercular  osteitis  is  apt  to  cause  tubercular  disease  in  an 
adjacent  joint.  Cold  abscesses  are  frequently  due  to  tuber- 
cular osteitis.  Caries  may  be  followed  by  amyloid  changes 
in  the  viscera. 

Symptoms. — In  the  beginning  the  evidences  of  caries 
are  usually  those  of  osteitis,  but  the  first  sign  noted  may 
be  a  fluctuating  swelling  due  to  pus  or  to  caseated  tubercles. 
After  a  time,  at  any  rate,  a  fluctuating  swelling  is  discovered. 
If  not  opened,  the  softened  mass  breaks  externally,  voids  its 
contents,  and  leaves  a  sinus  from  which  flows  caseated 
matter  which  after  a  time  becomes  thin,  reddish,  and  irritat- 
ing to  the  skin,  contains  small  portions  of  gritty  bone,  and 
has  a  foul  smell.  The  opening  of  the  sinus  fills  up  with 
edematous  granulations.  A  probe  carried  to  the  bottom 
of  the  sinus  finds  bone  which  is  sieve-like  (worm-eaten),  and 
which  on  being  struck  gives  a  muffled  note  rather  than  the 
clear,  sharp  note  of  necrosis ;  the  bone  is  rough,  is  bared, 


NECROSIS.  395 

and  is  so  soft  that  the  probe  can  usually  be  stuck  into  it.  In 
old  cases  of  caries  amyloid  disease  may  arise. 

Treatment. — If  syphilis  exists,  give  iodid  of  potassium  in 
advancing  doses  and  a  mild  mercurial  course.  If  tubercle  ex- 
ists, give  iodid  of  iron,  arsenic,  cod-liver  oil,  and  nourishing 
foods,  and  recommend  a  change  of  air.  Locally,  in  all  cases, 
insist  on  rest  and  at  once  secure  drainage,  enlarging  the 
opening  if  necessary  and  inserting  a  tube,  and  even  making 
additional  openings ;  syringe  often  with  antiseptic  fluids  and 
dress  antiseptically.  If  the  case  is  seen  before  spontaneous 
evacuation  has  occurred,  open  under  strict  antiseptic  pre- 
cautions. When  a  chronic  sinus  exists  there  arises  the 
question  of  operation.  Incomplete  operations  are  worse  than 
useless,  for  they  may  be  followed  by  diffuse  tuberculosis  or 
pyemia.  If  the  gouge  is  used,  try  to  remove  all  carious 
bone.  The  diseased  bone  is  white,  crumbles  up,  and  does 
not  bleed;  the  non-carious  bone  is  pink  and  vascular. 
Scrape  away  all  granulations ;  swab  the  cavity  with  pure 
carbolic  acid  and  pack  it  with  iodoform  gauze.  Instead  of 
gouging  away  bone,  there  may  be  used  the  actual  cautery, 
sulphuric  acid,  or  hydrochloric  acid.  In  severe  cases  exci- 
sion is  required,  and  in  some  rare  cases  amputation  may 
be  necessary.  Caries  of  the  spine  is  considered  under  Dis- 
eases of  the  Spine. 

Necrosis  is  the  death  of  visible  portions  of  bone  from 
circulatory  impediment.  It  is  analogous  to  gangrene.  The 
cause  of  necrosis  is  injury  (such  as  the  tearing  off  of  perios- 
teum) which  deprives  the  bone  of  blood.  Inflammation  of 
the  periosteum  further  lessens  the  nutrition.  Acute  inflam- 
mation in  bone  causes  necrosis,  the  excessive  exudation  in 
the  canals  and  spaces  occluding  the  blood-vessels  by 
pressure.  The  occlusion  of  vessels  by  septic  thrombi  may 
lead  to  necrosis,  or  the  direct  action  of  toxins  may  first 
inflame  and  finally  destroy  a  portion  of  the  bone.  A  thin 
shell  of  bone  only  may  necrose  from  periosteal  separa- 
tion, or  an  entire  shaft  may  die  from  acute  pyogenic  osteo- 
myelitis or  diffuse  infective  periostitis.  Osteomyelitis  is  the 
most  usual  cause  of  necrosis.  Necrosis  is  most  frequently  met 
with  in  the  diaphyses  of  the  long  bones,  caries  in  the  can- 
cellous tissue  of  bones.  The  ribs  may  become  carious,  but 
very  rarely  become  necrotic.  A  sequestrum  may  form  in  a 
vertebral  body,  in  the  carpus,  or  in  the  tarsus,  but  rarely  does  ; 
hence,  we  conclude  that  sequestra  do  not  often  result  from 
tubercular  osteitis.  A  fragment  of  dead  bone  as  a  foreign 
body ;  the  healthy  bone  adjacent  to  it  inflames  and  softens  ; 


396   DISEASES  AND   INJURIES   OF  BO.NES  AND  JOINTS. 

granulations  form,  and  this  line  of  granulation,  like  the  line 
of  demarcation  of  gangrene,  separates  the  dead  part  from  the 
living,  the  white  dead  bone  being  surrounded  by  the  red 
zone  of  granulation-tissue.  A  bit  of  dead  bone  is  called  a 
"  sequestrum,"  and  Nature  tries  to  cast  it  off  A  superficial 
sequestrum  is  known  as  an  "  exfoliation." 

Nature's  method  of  casting  off  a  sequestrum  is  as  follows  : 
suppuration  takes  place  at  the  line  of  demarcation,  osteitis 
extends  for  a  considerable  distance  around  this  line,  the  peri- 
osteum shares  in  the  inflammation,  and  new  bone  forms.  A 
cavity  is  thus  made  within  by  suppuration,  and  a  box  or  case 
forms  without  by  ossification,  the  now  entirely  loosened  se- 
questrum being  so  encased  that  it  cannot  escape.  The  pus 
finds  its  way  through  the  new  bone,  and  there  is  presented 
the  condition  so  often  seen  by  the  surgeon — namely,  a  case 
of  new  bone  known  as  the  "  involucrum,"  a  cavity  containing 
pus  and  the  dead  fragment  or  sequestrum,  and  a  discharging 


Fig.  108. — Diagram    illustrating  the   formation  of  a  sequestrum  :    A,  sound  bone ;  B,    new 
bone  ;    C,  granulations  lining  involucrum  ;  D,  cloaca  ;  £,  sequestrum. 

sinus  or  "cloaca"  (Fig.  108).  Nature  may  eventually  get 
rid  of  the  fragment,  but  the  surgeon  should  not  wait  for  the 
completion  of  this  slow  process. 

When  a  portion  of  the  bone  surrounding  the  medullary 
canal  dies  the  condition  is  called  "  central  necrosis."  In 
some  rare  cases  necrosis  occurs  without  apparent  suppura- 
tion, a  painless  swelling  of  bone  simulating  sarcoma.  This 
condition  is  known  as  quiet  necrosis,  and  has  been  described  by 
Sir  James  Paget  and  Mr.  Morrant  Baker.  Mercury  is  an  oc- 
casional cause  of  necrosis.  The  fumes  of  phosphorus  may 
cause  necrosis  of  the  lower  jaw  in  those  with  decayed  teeth. 
Necrosis  may  be  produced  also  by  frost-bites  and  burns. 
Many  fevers  (measles,  typhoid,  scarlet  fever,  etc.)  are  occa- 
sionally followed  by  necrosis.  Syphilis  and  tuberculosis 
are  occasional  causes. 


A'ECROSIS.  397 

Symptoms. — The  symptoms  of  necrosis  are  at  first  those 
of  osteitis  or  osteomyelitis.    The  abscess,  when  formed,  opens 
of  itself  or  is  opened  by  the  surgeon,  and  a  sinus  or  sinuses 
form  in  the  soft  parts  a's  happens  in  caries.     A  probe  intro- 
duced into  the  sinus  strikes  upon  hard  bone  a\  ith  a  clear, 
rino-ing  note,  and  often  finds  a  sinus  or  sinuses  ui  the  bone. 
In  ^superficial  necrosis  the  discharge  is  slight  and  the  probe 
shows  the  limitations  of  the  disease.     In  extensive  necrosis 
the  discharge  is  profuse,  much  new  bone  forms,  several  sinuses 
appear  far  apart,  and  the  probe  must  pass  through  a  consid- 
erable thickness  of  new  bone  before  it  finds  the  bit  of  dead 
bone.     The  surgeon  should  not  operate  until  the  dead  bone 
is  separated  from  the  hving  by  a   line  of  demarcation,  and 
until  the  sequestrum  is  loose.     In  youth  dead  bone  loosens 
quickly,  but  in  old  age  slowly.     An  exfoliation  becomes  loose 
sooner  than  the  sequestrum  of  central  necrosis.     In  diffuse 
periostitis  the  necrosed  shaft  loosens  quickly.     Necrosed  por- 
tions of  the  upper  extremity  loosen  more  rapidly  than  those 
of  the  lower.    Chilton  says  that  in  the  young  adult  tw'o  or  three 
months  will  be  required  to  loosen  a  necrosed  fragment  in  the 
lower  extremit)',  and  from  six  w-eeks  to  two  months  m  the 
upper  extremity-.     A  loose  sequestrum  may  be  moved  by  the 
probe,  and  when  struck  gives  a  hollow  note.     In  protracted 
cases  of  necrosis  there  is  always  danger  that  am>-loid  disease 

mav  arise. 

Ouiet  necrosis  is  a  rare  condition  which  has  led  to  some  de- 
plorable but  pardonable  mistakes,  because  it  resembles  ossify- 
ing sarcoma.  It  follows  injur}-,  particularly  fracture.  The 
bolie  enlarges  greatly.  There  is  little  or  no  pain  and  no  fever. 
The  diagnosis  can  only  be  m.ade  by  exploratory  incision, 
and  it  may  even  be  necessaiy  to  remove  portions  for  micro- 
scopic stu'dv  before  a  conclusion  can  be  reached. 

Postfebrile  necrosis  is  most  usually  met  with  after  t}-phoid 
fever.  The  bacilli  of  tj^phoid  cause  osteomyelitis,  and  this 
is  followed  by  necrosis.  Scarlet  fever,  measles,  and  other 
febrile  processes  may  also  induce  necrosis.  It  is  certain  that 
bacilli  accumulate  in  the  bones  during  t}-phoid  fever.  They 
mav  promptly  induce  disease  ;  they  may  remain  tor  long 
periods  apparently  inactive  and  finally  pass  away  ;  or  after  a 
slicrht  strain  or  injury-  these  organisms  may  induce  bone 
dis^'ease  months  or  even  years  after  the  primar)-  infection. 
Typhoid  bone  disease  is  often  multiple,  many  bones  being 
involved  successively .^  Not  unusually  after  t)-phoid  fever 
muscle  strain  causes  periostitis  and  osteitis,  and  at   such  a 

1  Keen's  Surgical  Complications  of  Typhoid  Fever. 


398   DISEASES  AND  INJURIES   OF  BONES  AND  JOINTS. 

point  necrosis  may  occur.  Either  exfoliation,  or  central 
necrosis,  may  follow  typhoid  fever.  The  tibia  is  involved 
more  often  than  other  bones. 

Treatment. — An  exfoliation  should  be  removed  as  soon 
as  it  becomes  loose,  the  seat  of  trouble  should  be  touched 
with  pure  carbolic  acid,  and  packing  of  iodoform  gauze 
should  be  inserted.  The  treatment  of  central  necrosis  com- 
prises free  incisions  for  drainage,  antiseptic  dressing,  fre- 
quent cleansing,  rest,  nourishing  food,  stimulants,  and  tonics. 
When  the  sequestrum  becomes  loose  the  involucrum  should 
be  broken  through  with  the  chisel,  gouge,  and  rongeur.  The 
dead  bone  should  be  removed  and  the  cavity  scraped,  irrigated 
with  hot  salt  solution,  dried,  painted  with  pure  carbolic  acid, 
and  packed  with  iodoform  gauze.  This  operation  is  known 
as  "  sequestrotomy."  If  much  of  a  gap  is  left  by  the  opera- 
tion, the  surgeon  should  try  to  fill  it  by  taking  flaps  of  skin 
and  fastening  them  to  the  bottom  with  nails  (Neuber's  opera- 
tion), by  breaking  the  edges  of  the  involucrum  and  turning 
them  in,  or  by  inserting  bone-chips.  Bone-chips  are  obtained 
from  the  compact  part  of  the  tibia  or  femur  of  an  ox,  and  are 
decalcified  by  being  placed  for  a  couple  of  weeks  in  a  10  per 
cent,  aqueous  solution  of  hydrochloric  acid  (which  is  renewed 
every  day) ;  they  are  well  washed  in  a  weak  alkali  and  then 
in  water,  are  cut  into  strips,  are  soaked  for  two  days  in  a 
I  :  1000  solution  of  corrosive  sublimate,  and  are  kept  until 
needed  in  a  saturated  ethereal  solution  of  iodoform.  The 
cavity  is  made  sterile  and  is  well  dusted  with  iodoform,  the 
bone-chips  are  dried  and  inserted  into  the  cavity,  a  capillary 
drain  is  employed,  the  periosteum  is  stitched  over  the 
opening,  and  the  soft  parts  are  sutured ;  but  if  this  cannot  be 
done,  iodoform  packing  is  used  to  keep  the  chips  in  place. 
This  method  we  owe  to  the  genius  of  Senn.  Attempts  have 
been  made  to  fill  bone-cavities  with  gutta-percha,  plaster 
of  Paris,  etc.  (Martin).  Schleich  uses  formalin-gelatin  to  fill 
bone-cavities.  The  difficulty  is  to  completely  asepticize  the 
walls  of  the  cavity.  Dressman  has  advised  for  this  purpose 
the  use  of  boiling  oil,  but  it  is  apt  to  cause  superficial  necro- 
sis. In  some  cases  of  widespread  necrosis  due  to  diffuse  in- 
fective osteoperiostitis  or  to  osteomyelitis  extensive  resection, 
or  even  amputation,  may  be  necessary. 

Acute  osteomyelitis  is  an  acute  and  diffuse  inflam- 
mation of  the  bone-marrow  due  to  pyogenic  organisms. 
Infection  from  staphylococci  may  be  hmited  to  a  portion  of 
one  bone.  Streptococcus  infection  causes  widespread  involve- 
ment  of  a   bone  or  of  several  bones.     Acute  osteomyelitis 


ACUTE    OSTEOMYELITIS.  399 

may  be  due  to  mixed  infection  with  bacilli  of  typhoid  and 
pyogenic  organisms,  or  bacilli  of  tubercle  and  pyogenic 
organisms,  a  typhoid  process  or  a  tubercular  process  servnig 
tolistablish  a  point  of  least  resistance. 

The  pyogenic  organisms  may  gain  entrance  directly  by 
way  of  a  wound  (a  gunshot-wound,  a  compound  fracture, 
an  amputation).  The  causative  organisms  may  reach  the 
bone  by  way  of  the  blood,  having  entered  the  blood  origi- 
nally through  the  lymphatic  system  or  from  a  focus  of  sup- 
puration in  the  skin,  the  subcutaneous  tissue,  or  a  deeper 

part.  r  u  -1 

Pus  organisms  may  pass  into  the  blood  from  the  tonsils 
or  respiratory  organs  (Kraske);  the  intestinal  canal  (Kocher) ; 
the  o-enito-urinary  tract;  or  from  excoriations,  bruises,  or 
smalt  wounds  in  the  skin  (Warren).  Certain  fevers  strongly 
predispose  to  the  disease  by  preparing  the  soil  as  it  were 
for  the  growth  of  pyogenic  bacteria.  Typhus  fever,  small- 
pox, mdarial  fever,  scarlet  fever,  measles,  and  diphtheria 
lessen  the  vital  resistance  of  bone-marrow.  Typhoid  fever 
is  not  unusually  followed  by  a  chronic  osteomyelitis,  due 
solely  to  typhoid  bacilli.  If  mixed  infection  with  pus 
organisms  occurs,  acute  osteomyelitis  arises.  Vital  resistance 
of  ^marrow  is  lessened  by  exhausting  diseases,  overexertion, 
unhealthy  and  especially  putrid  food.  When  organisms 
gain  entrance  directly  by  a  wound  (as  in  a  compound  fract- 
ure) the  endosteum,  the  medulla,  and  the  cancellous  tissue 
inflame  and  suppurate,  and  the  entire  length  and  thickness 
of  the  bone  may  be  involved.  The  periosteum  becomes 
infiltrated,  detached  from  the  bone,  and  retracted  from  the 
edges  of  the  wound  in  the  bone.  The  soft  tissues  around 
the  bone  may  inflame,  suppurate,  or  slough.  More  or  less 
necrosis  inevitably  occurs. 

Acute  osteomyelitis  without  a  wound  is  often  called  acute 
epiphysitis  or  acute  infantile  arthritis.  This  condition  is  most 
common  in  infants  or  children  of  one  to  two  years  of  age, 
but  occasionally  arises  in  older  children  (from  ten  to  four- 
teen years).  It  is  most  common  during  the  period  of  active 
growth  of  bone.  It  is  frequently  preceded  by  one  of  the 
predisposing  causes  before  mentioned.  In  many  cases  a  strain 
or  bruise  is  followed  by  pyogenic  infection,  because  the 
damaged  tissue  extends  a  hospitable  welcome  to  micro- 
organisms which  are  traveUing  in  the  body-fluids  and  pass 
through  the  injured  area.  In  some  cases  chilling  of  the  sur- 
face of  the  body  is  a  predisposing  cause.  In  others  no  pre- 
disposing cause  is  discoverable. 


400  DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

The  compact  bone  suffers  secondarily,  but  is  never  attacked 
primarily.  New  tissue  is  more  susceptible  to  infection  than 
old  tissue,  and  the  disease,  as  a  rule,  begins  near  the  epiph- 
yseal line,  where  new  bone  is  being  formed.  This  point 
was  spoken  of  by  Oilier  as  "the  zone  of  election  of  patho- 
logical processes."  Warren  points  out  that  in  a  growing 
bone  near  the  epiphyseal  cartilage  there  exists  a  newly- 
form.ed  spongy  tissue,  very  vascular  and  connected  with  the 
cartilage  by  a  spongy  layer  of  tissue,  which  is  not  yet  bone, 
but  which  does  not  possess  a  cartilaginous  structure.  It  is 
in  this  portion  of  the  skeleton  that  the  most  active  changes 
take  place  during  the  period  of  growth.  The  medullary 
substance  is  very  vascular  at  this  point ;  it  is  red  and  with- 
out fatty  tissue.  It  communicates  with  the  medullary  canal 
and  with  the  periosteum  by  a  number  of  vascular  channels. 
The  epiphyseal  cartilage  itself  is  intimately  blended  with  the 
periosteum.  The  diaphyseal  side  of  the  cartilage  produces 
much  more  bone  than  is  found  in  the  epiphyseal  margin. 
There  is  also  an  active  growth  of  bone  in  the  periosteum, 
and  it  is  in  these  regions  and  in  the  medullary  canal  that 
the  inflammatory  process  originates.^  The  lower  end  of  the 
femur  and  the  upper  end  of  the  tibia  are  the  regions  most 
commonly  attacked;  but  the  upper  end  of  the  femur  and 
the  lower  end  of  the  tibia  may  suffer,  and  other  bones  may 
be  attacked,  especially  the  humerus,  radius,  ulna,  and  infe- 
rior maxilla.  The  adjacent  joint  not  unusually  becomes 
involved.  Though  the  inflammation  begins  in  the  spongy 
tissue  or  medulla,  it  passes  to  the  canals  and  spaces  of  the 
compact  bone.  The  inflammatory  exudate  in  the  canals 
compresses  the  vessels  and  cuts  off  nutrition  from  certain 
areas.  Suppuration  begins,  clots  form  in  the  medulla  from 
thrombophlebitis,  and  the  clots  in  the  vessels  of  the  Haver- 
sian canals  become  septic.  A  small  sequestrum  forms  at 
the  seat  of  origin  of  the  disease,  and  the  pus  about  the 
sequestrum  is  apt  to  empty  into  the  medullary  canal,  caus- 
ing diffuse  osteomyelitis,  or  into  the  adjacent  joint,  causing 
suppurative  inflammation  of  the  articulation. 

Marked  constitutional  symptoms  arise  from  absorption  of 
toxins  (sapremia),  and  sometimes  true  septic  infection  or  even 
pyemia  arises. 

Very  extensive  necrosis  may  follow  osteomyelitis  if  the 
patient  recovers. 

Symptoms. — OsteomyeHtis  secondary  to  a  wound  may 
occur  in  a  person  of  any  age.     If  a  wound  exists,  for  in- 

*  Warren's  Surgical  Pathology. 


ACUTE    OSTEOMYELITIS.  4OI 

Stance  a  compound  fracture,  the  diagnosis  is  evident.  The 
constitutional  symptoms  of  septic  absorption  are  positive : 
there  is  a  profuse,  offensive,  purulent  discharge  containing 
bone-fragments  and  tissue-sloughs ;  the  periosteum  is  red, 
thick,  and  separated ;  there  are  swelling  over  the  bone,  great 
tenderness,  and  violent  boring,  gnawing,  or  aching  pain. 
Osteomyelitis  occurring  without  a  wound,  the  condition 
known  as  acute  epiphysitis,  occurs  in  the  young,  and  par- 
ticularly in  children  under  three  years  of  age. 

The  symptoms  of  acute  epiphysitis  usually  come  on  sud- 
denly and  especially  at  night,  and  the  attack  may  be  so, 
acute  as  to  cause  death  by  systemic  poisoning  before  a  diag- 
nosis is  arrived  at.  The  disease  is  generally  ushered  in  by 
a  chill,  which  is  followed  by  septic  febrile  temperature.  The 
history  will  sometimes  contain  the  statement  that  a  blow 
was  received,  that  a  febrile  process  had  existed,  or  that  the 
patient  was  suddenly  chilled  after  being  overheated  (sitting 
in  a  draft  or  in  a  cellar  on  a  hot  day,  possibly  swimming 
when  \-ery  warm,  etc.).  There  is  violent  aching  pain  in  the 
bone  and  acute  tenderness  near  the  joint;  the  soft  parts,  which 
at  first  are  healthy  in  appearance,  after  a  time  discolor,  swell, 
and  present  distended  veins,  and  may  become  glossy  and 
edematous  because  pus  is  gathered  below.  An  abscess  often 
reaches  the  surface  and  may  break  spontaneously.  The 
neighboring  joint  swells,  and  may  become  filled  with  pus  ; 
the  periosteum  and  the  shaft  are  involved  for  a  considerable 
distance;  each  epiphysis  may  become  affected,  the  shaft 
between  being  comparatively  uninvolved,  and  the  epiph}-ses 
may  separate,  displacement  and  shortening  taking  place. 
This  disease  is  often  mistaken  for  rheumatism  because  of 
the  joint-swelling,  occasionally  for  typhoid  fever  because  of 
the  fever,  and  in  some  cases  for  erysipelas  because  of  the 
redness  of  the  skin.  It  gives  a  very  grave  prognosis. 
Sometimes  an  epiphysitis  shows  milder  symptoms  and  is 
slower  in  progress  (subacute).  These  cases  are  ver}"  often 
mistaken  for  rheumatism.  But  in  rheumatism  the  joint  is 
the  part  involved  from  the  beginning,  Avhile  in  epiphysitis 
the  joint  is  involved  secondarily  after  obvious  evidence  of 
inflammation  well  clear  of  the  articulation.  Further,  the 
s}-mptoms  of  rheumatism  will  be  rapidly  improved  b}'  the 
use  of  the  alkalies  or  the  salicylates. 

Treatment. — If  a  wound  exists,  apply  a  tourniquet,  steril- 
ize the  parts,  enlarge  the  wound,  expose  and  curet  the 
medullary  cavity,  remove  loose  fragments  of  bone,  irrigate 
the  medullary  cavit)-  with  a  hot  solution  of  corrosive  subli- 

26 


402   DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS. 

mate  or  hot  salt  solution,  scrape  it,  paint  with  pure  carbolic 
acid,  pack  lightly  with  iodoform  gauze,  dress  with  hot  anti- 
septic fomentations,  and  secure  rest  for  the  part  by  splints 
and  bandages.  The  constitutional  treatment  is  the  same  as 
that  for  septicemia.  Acute  epiphysitis  is  a  most  serious 
condition,  rapidly  progressive,  apt  to  be  quickly  fatal,  and 
requiring  prompt  and  radical  treatment.  In  treating  acute 
epiphysitis  do  not  wait  for  fluctuation,  but  incise  at  once; 
break  through  the  bone  at  one  or  more  points  with  a  gouge 
or  chisel;  chisel  away  the  diseased  bone,  and  if  necessary 
curet  the  medullary  canal;  irrigate  with  hot  corrosive-subli- 
mate solutions  or  hot  salt  solution;  swab  with  pure  car- 
bolic acid;  use  iodoform  plentifully;  pack  with  iodoform 
gauze;  dress  with  hot  antiseptic  fomentations;  drain  the  joint 
if  it  is  involved;  employ  rest,  anodynes,  strong  supporting 
treatment,  and  other  remedies  advised  in  septicemia.  Remove 
dead  bone  subsequently  when  it  becomes  loose.  Amputa- 
tion may  be  required  in  either  form  of  the  disease. 

Chronic  osteomyelitis  is  usually  linked  with  osteitis. 
It  may  eventuate  in  osteosclerosis  with  filling  up  of  the 
medullary  canal,  in  hmited  suppuration,  in  caseation  of 
the  cancellous  tissue  (Brodie's  abscess),  or  in  necrosis.  A 
tubercular  inflammation  is  one  form  of  chronic  osteomye- 
litis.    Syphilis,  typhoid  fever,  etc.,  may  cause  it. 

The  typhoid  bacillus  is  pyogenic.  Frankel  taught  this 
some  years  ago,  and  Keen  seems  to  prove  it  in  his  work  on 
the  surgery  of  typhoid  fever.  Osteomyelitis  due  purely  to 
typhoid  bacilli  is  chronic.  When  the  medulla  contains 
typhoid  bacili  pus  infection  is  apt  to  take  place,  and  if  such 
a  mixed  infection  arises  acute  osteomyelitis  develops. 

In  chronic  osteomyelitis  there  are  pain,  tenderness,  and 
swelling,  but  no  constitutional  symptoms.  In  some  cases 
the  real  trouble  is  not  identified  until  an  abscess  forms  (see 
Necrosis). 

Treatment. — Evacuate  an  abscess  and  remove  dead 
bone. 

Osteomalacia,  or  Mollities  Ossium. — In  this  disease 
the  bones  are  partly  decalcified,  and  consequently  soften 
and  bend.  Many  bones  are  usually  involved.  It  is  com- 
moner beyond  than  before  middle  age,  though  it  may  occur 
in  infancy ;  it  is  more  frequently  met  with  in  women  than  in 
men,  and  pregnancy  seems  to  bear  more  than  a  casual  rela- 
tion to  its  production.  In  osteomalacia  the  medulla  increases 
in  bulk  and  becomes  more  fatty,  and  the  osseous  matter  is 
absorbed  gradually,  first  from  the  cancellous  tissue  and  then 


LEONTIASIS   OSSIUM.  403 

from  the  compact  tissue.  Some  observers  believe  this  curious 
condition  is  due  to  lactic  acid  in  the  blood. 

Symptoms. — The  symptoms  of  osteomalacia  are  as  fol- 
lows :  many  points  of  pain  which  are  often  thought  to  be 
due  to  rheumatism  ;  deformities  from  twisting  and  bending 
of  bone ;  and  a  large  excess  of  calcium  salts  in  the  urine. 
This  disease  lasts  a  number  of  years,  but  usually  causes 
death  from  exhaustion,  though  some  few  cases  are  arrested 
or  cured.     Fractures  occur  from  very  slight  force. 

Treatment. — In  treating  osteomalacia  in  women  insist 
that  pregnancy  must  not  occur.  Put  braces  and  supports 
upon  distorted  limbs  to  prevent  fracture.  Advise  good  air, 
hygienic  surroundings,  and  nourishing  food.  Among  the 
medicines  that  can  be  used  may  be  mentioned  cod-liver  oil, 
lime  salts,  preparations  of  phosphorus,  and  bone-marrow. 
In  women  the  removal  of  the  ovaries  sometimes  produces 
cure.  It  has  been  asserted  that  the  production  of  anesthesia 
by  means  of  chloroform  may  be  of  benefit. 

Acromegaly. — This  is  a  disease  which  causes  progres- 
sive and  often  great  enlargement  of  both  the  bones  and  soft 
parts  of  the  extremities,  which  enlargement  is  symmetrical. 
The  lower  jaw  projects  in  advance  of  the  upper  jaw,  the  nose 
becomes  prominent  and  thick,  the  supraorbital  ridges  are 
accentuated,  and  the  costal  cartilages  and  inner  ends  of  the 
clavicles  become  protuberant.  Later  the  larynx,  ribs,  shoul- 
der-blades, and  vertebrae  become  involved,  and  the  back 
becomes  markedly  humped  (cervicodorsal  hump).  The  hands 
and  feet  are  affected  in  advanced  cases.  As  a  rule,  the 
thyroid  gland  is  enlarged,  and  a  post-mortem  examination 
may  detect  an  enlarged  pituitary  gland.  Severe  and  uncon- 
trollable headache  is  sometimes  a  distressing  feature  of  the 
disease.  Treatment  is  futile.  The  disease  slowly  but  surely 
causes  death. 

I^eontiasis  Ossium  (Virchow's  Disease).— This  is  a 
hypertrophy  limited  to  the  facial  and  cranial  bones,  which 
is  symmetrical,  and  which  begins,  as  a  rule,  in  the  superior 
maxilla:;.  The  hypertrophy  progressively  increases,  causes 
difficulty  of  mastication,  and  is  accompanied  by  headache. 
It  produces  distinct  deformity  of  the  jaw  like  a  tumor, 
whereas  acromegaly  enlarges  all  of  the  proportions  of  a 
bone.  Treatment  is  not  satisfactory,  as  a  rule.  Recently 
Horsley  has  obtained  amelioration  by  operating  and  remov- 
ing masses  of  bone. 


404  diseases  and  injuries  of  bones  and  joints. 

2.  Fractures. 

Definition. — A  fracture  is  a  solution,  by  sudden  force, 
of  the  continuity  of  a  bone  or  of  a  cartilage.  Clinically, 
under  this  head  are  placed  epiphyseal  separations  and  the 
tearing  apart  of  ribs  and  their  cartilages. 

Varieties  of  Fractures. — The  varieties  of  fractures  are 
as  follows : 

Shnple  fractiirc  is  a  subcutaneous  fracture,  or  one  in  which 
there  is  no  wound  extending  from  the  surface  to  the  seat  of 
bone-injury.  This  corresponds  to  a  contusion  of  the  soft 
parts. 

Compound  fracture  is  an  open  fracture,  or  one  in  which 
an  open  wound  extends  from  the  surface  to  the  seat  of  bone- 
injury  or  in  which  a  wound  opens  up  a  passage  from  the 
fracture  to  the  surface.  This  corresponds  to  a  contused  or 
lacerated  wound  of  the  soft  parts.  The  opening  may  be 
through  the  skin  ;  through  a  mucous  membrane,  as  in  some 
fractures  of  the  base  of  the  skull  and  pelvis  ;  through  the 
drum  of  the  ear,  as  in  some  fractures  of  the  middle  fossa  of 
the  base  of  the  skull ;  through  the  lung,  as  when  a  broken 
rib  penetrates  that  organ  ;  or  through  the  bowel  or  bladder, 
as  in  some  fractures  of  the  pelvis. 

A  primary  compound  fracture  is  one  in  which  the  breach 
in  the  soft  parts  is  produced  at  the  time  of  the  accident, 
either  by  the  direct  violence  of  the  injury  or  by  the  forcing 
of  a  bone  or  bones  through  the  tissues. 

A  secondary  compound  fracture  is  one  in  which  the  breach 
in  the  soft  parts  occurs  after  the  accident,  either  from  slough- 
ing of  damaged  tissues,  from  ulceration  because  of  the  press- 
ure of  ill-adjusted  fragments,  or  from  the  forcing  of  a  bone 
or  bones  through  the  soft  parts  because  of  rough  handling, 
neglect,  or  the  tossing  of  delirium. 

Complicated  fraci7ire  is  a  fracture  plus  the  complication 
of  a  joint-injury,  arterial  or  venous  damage,  or  injury  to 
the  nerves  or  soft  parts.  When  a  fractured  rib  injures  the 
lung  or  when  a  broken  vertebra  damages  the  cord  a 
complicated  fracture  exists.  The  term  is  unfortunate,  as  it 
conveys  no  definite  meaning,  and  its  use  is  no  more  justi- 
fiable than  it  would  be  to  speak  of  "  complicated  pneu- 
monia "  or  "  complicated  typhoid,"  for  the  complication 
should  be  named  in  any  case.  It  must  be  remembered 
that  damage  to  the  soft  parts  not  sufficiently  severe  to  pro- 
duce a  wound  reaching  from  the  surface  to  the  seat  of  fract- 
ure does  not  make  the  case  a  compound  fracture,  but  rather 


VARIETIES   OE  ERACTURES.  4° 5 

complicates  a  simple  fracture.  Remember  also  that  even 
superficial  areas  of  tissue-destruction  must  be  treated  anti- 
septically,  otherwise  absorption  of  pyogenic  bacteria  and 
their  deposition  at  the  seat  of  injury  may  cause  diffuse 
osteomyelitis. 

Complete  fracture  is  that  A\hich  extends  through  the  whole 
thickness  of  a  bone  or  entirely  across  it. 

Incomplete  fracture  is  that  which  extends  only  partially 
through  the  thickness  of  a  bone  or  only  partially  across  it. 
A  linear  hair,  capillary,  or  fissured  fracture,  or  a  fissure, 
is  a  crack  in  a  bone  with  very  little  separation  of  the  edges. 
This  is  an  incomplete  fracture,  but  may  be  associated  with  a 
complete  break. 

A   crrcen-stick,  hickory-stick,  tuillozv,  or  bent  fracture  is  a 
true  incomplete  break.     It  is  commonest  in  the  forearm  and 
clavicle  it  arises  from  indirect  force,  and  it  is  very  rare  after 
the  age  of  sixteen.     It  is  called  "green-stick"  because  the 
bone  breaks  like  a  green  stick  when  forced  across  the  knee, 
first  bending  and  then  breaking  on  its  convex  surface.     The 
bone  being  compressed  between  two  forces,  bends,  and  the 
fibers  on  the  outer  side  of  the  curve  are  pulled  apart,  while 
those  on  the  concavity  are  not  broken,  but  are  compressed. 
In  correcting  the  deformity  such  fractures  are  often  made 
complete       The  permanent  bending  of   a  bone  without  a 
break  may  possibly  occur  in  youth.     In  children  a  portion 
of  a  bone  of  the  skull  may  be  bent  inward,  causing  depres- 
sion     In  some  cases  such  a  depression  is    permanent ;   in 
others  it  is  temporary,  the  bone  returning  to  its  proper  level. 
Depression-fracture  occurs  when  a  portion  of  the  thickness 
of  a  bone  is  driven  in  by  crushing.     Fracture  by  depression 
is  a  result   of  the  bending  in  of  a  bone  (as  the  parietal),  a 
fracrment  breaking  off  from  the  side  toward  which  the  bone 
is  bending.     A  depressed  fracture  is  complete,  not  incom- 
plete and  by  this  term  is  meant  an  injury  in  which  a  frag- 
ment of  the  entire  thickness  of  the  bone  is  driven  below  the 
level  of  the  surrounding  surface. 

Splinter-  and  Strain fracture.—Th&  breaking  off  ot  a 
splinter  of  bone  (splinter-fracture)  or  of  an  apophysis  con- 
stitutes a  form  of  incomplete  fracture.  A  strain  upon  a  liga- 
ment or  a  tendon  may  tear  off  a  shell  of  bone,  and  this  in- 
jury is  the  "  strain-fracture  "  or  "  sprain-fracture  "  of  Callander. 
Lono-itudinal  fracture  is  a  fracture  whose  line  is  for  a  con- 
siderable distance  parallel,  or  nearly  so,  with  the  long  axis 
of  the  bone.  Such  fractures  are  common  in  gunshot-injuries. 
Oblique  fracture  is  a  fracture  the  direction  of  which  is  pos- 


406   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

itively  oblique  to  the  long  axis  of  the  bone.  Most  fractures 
from  indirect  force  are  oblique. 

Transverse  fracture  is  a  fracture  the  direction  of  which  is 
nearly  transverse  to  the  long  axis  of  the  bone  (no  fracture  is 
mathematically  transverse).  The  cause  is  often  but  not  in- 
variably direct  force.  The  ''fracture  en  rave''  (radish- 
fracture,  so  called  because  the  bone  breaks  as  does  a  radish) 
is  transverse  at  the  surface,  but  not  within. 

Toothed  or  dentate  fracture  is  a  form  of  fracture  in  which 
the  end  of  each  fragment  is  irregularly  serrated  and  the  frag- 
ments are  commonly  locked  together ;  hence  it  is  difficult 
to  correct  the  deformity.  Most  simple  fractures  from  direct 
force  are  serrated. 

Wedge-shaped,  V-shaped,  cuneatcd,  or  cuncform  fracture 
("  fracture  oblique  spiroide,"  "  fracture  en  V  "  of  Gosselin, 
"  fracture  en  coin  ")  is  a  fracture  the  lines  of  which  take  the 
shape  of  a  V,  which  may  be  entire  or  may  lack  the  point. 
It  occurs  at  the  articular  extremity  of  a  long  bone,  and  a 
fissure  usually  arises  from  its  point  and  enters  the  joint.  If 
complete,  it  is  a  "  comminuted  fracture." 

T-shaped  fracture  is  a  fracture  which  presents  a  transverse 
or  oblique  line  and  also  a  longitudinal  or  vertical  line.  It 
occurs  at  the  lower  end  of  either  the  humerus  or  femur,  the 
transverse  line  being  above,  and  the  vertical  line  (intercon- 
dyloid)  between,  the  condyles.  If  complete,  it  is  in  reality  a 
form  of  comminuted  fracture. 

Multiple  or  composite  fracture  is  a  condition  in  which  a 
bone  is  broken  into  more  than  two  pieces,  the  lines  of  fract- 
ure not  intercommunicating,  or  a  condition  in  which  two  or 
more  bones  are  broken.  Multiple  fractures  of  one  bone  are 
divided  into  double,  treble,  quadruple,  etc. 

Comminuted  fracture  is  a  condition  in  which  a  bone  is 
broken  into  more  than  two  pieces,  the  lines  of  fracture  inter- 
communicating. The  bone  may  be  broken  into  many  small 
fragments,  there  may  be  much  splintering,  or  the  osseous 
matter  may  actually  be  ground  up. 

Impacted  fracture  is  one  in  which  one  fragment  is  driven 
into  the  other  and  solidly  wedged. 

Fracture  with  crushing  ox  penetration  is  a  fracture  in  which 
one  bone  is  driven  into  the  other,  the  encasing  bone  being  so 
splintered  that  the  impacting  bone  is  not  firmly  held. 

Pathological,  spontaneous,  or  secondary  fracture  is  one 
occurring  from  a  very  insignificant  force  acting  on  a  bone 
rendered  brittle  by  disease. 

Un^inited  fracture  is  a  term  used  to  designate  a  fracture 


CAUSES   OF  FRACTURE.  407 

in  which  bony  union  is  absent  after  the  passage  of  the  period 
norniall}'  necessary  for  its  occurrence. 

Direct  fracture  is  one  occurring  at  the  point  at  wliich  the 
force  was  primarily  apphed. 

Indirect  fracture  is  one  occurring  at  a  point  distant  from 
the  area  of  the  primary  appHcation  of  force. 

Stellate ,  ox  starred,  fracture  (fracture  par  irradiation)  is  one 
in  which  several  fissures  radiate  from  a  center.  If  the  fract- 
ures be  complete,  the  condition  is  in  reality  a  form  of  com- 
minuted fracture. 

Helicoidal,  spiral,  or  torsion  fracture  is  a  fracture  resulting 
in  a  long  bone  from  twisting. 

Fracture  by  contrecoup  is  a  fracture  of  the  skull  which  is 
on  the  opposite  side  of  the  head  to  that  which  was  the 
recipient  of  the  force. 

Epiphyseal  Separation  or  Diastasis. — This  injury  occurs 
only  before  the  age  of  twenty-five  and  is  commonest  at  the 
lower  end  of  the  femur,  but  it  is  encountered  also  at  the 
lower  ends  of  the  tibia  and  radius  and  at  both  extremities  of 
the  humerus.  This  injury  induces  deformity,  which  is  often 
difficult  to  reduce,  and  by  damaging  the  cartilage  may  retard 
or  inhibit  a  further  lengthening  of  the  limb  by  growth. 

Intra-titerine  fractures  are  usually  due  to  injuries  of  the 
mother's  abdomen  sustained  toward  the  end  of  pregnancy. 
Some  hold  that  they  can  arise  as  a  consequence  of  the  force 
of  violent  uterine  contractions.  Many  so-called  "  intra-ute- 
rine  "  fractures  are  wrongly  named,  as  they  result  from  injuiy 
during  delivery.  In  sporadic  cretinism  the  bones  are  fragile 
and  ill-ossified,  and  many  fractures  may  occur  in  utcro. 

Designations  According  to  Seat  of  Fractures. — Fractures 
are  designated  also  according  to  their  anatomical  seats ;  for 
instance,  fracture  of  the  upper  third  of  the  shaft  of  the  femur, 
fracture  of  the  olecranon  process  of  the  ulna,  fracture  of  the 
middle  third  of  the  clavicle,  and  fracture  of  the  bod}^  of  the 
lower  jaw^  Intra-articular  fracture  is  one  extending  into  a 
joint;  intracapsidar  fracture  is  one  Avithin  the  capsule  of 
either  the  shoulder-  or  hip-joint ;  and  extracapsular  fracture 
is  one  just  without  the  capsule  of  either  the  shoulder-  or 
hip-joint. 

Causes  of  Fracture. — The  causes  of  fracture  are  (i)  ex- 
citing, immediate  or  direct,  and  (2)  predisposing  or  indirect. 

Exciting  causes  are  {a)  external  violence  and  {b)  muscu- 
lar action. 

External  violence  is  the  most  usual  exciting  cause.  Two 
forms  are  noted  :  (i)  direct  violence  and  (2)  indirect  force. 


408   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

Fractures  from  direct  violence  occur  at  the  point  struck,  as 
when  the  nasal  bones  are  broken  with  the  fist.  In  such  fract- 
ures the  soft  parts  are  damaged ;  they  may  be  destroyed  at 
once  in  part,  they  may  be  damaged  so  severely  that  a  portion 
sloughs,  or  they  may  be  damaged  so  slightly  that  they  do 
not  lose  vitality;  hence  fractures  by  direct  violence  may  be 
compound  from  the  start,  may  become  so,  or  may  remain 
simple.  In  fractures  by  direct  force  discoloration,  due  to 
effused  blood,  usually  appears  at  the  point  struck  soon  after 
the  accident.  In  compound  fractures  by  direct  violence  the 
soft-part  injury  is  so  great  that  primary  tissue-union  cannot 
occur. 

Fractures  from  indirect  force  do  not  occur  at  the  point  of 
application  of  the  force,  but  at  a  distance  from  it,  the  force 
being  transmitted  through  a  bone  or  a  chain  of  bones,  as 
when  the  clavicle  is  broken  by  a  fall  upon  the  extended  hand. 
Such  fractures  tend  to  occur  in  regions  of  special  predilection. 
If  they  are  not  compound,  there  is  no  injury  of  the  surface 
over  the  fracture.  If  they  become  compound  by  projection 
of  fragments,  primary  union  may  still  occur.  Discoloration 
over  the  seat  of  fracture  is  usually  not  present  soon  after  the 
accident,  but  may  occur  later.  Discoloration  rapidly  appears 
in  soft  parts  at  the  point  where  the  force  was  first  applied. 

Miiscidar  action  is  a  rather  rare  cause.  Fractures  thus 
produced  result  from  sudden  or  violent  contraction.  Bones 
so  broken  are  usually  diseased.  Violent  coughing  may  fract- 
ure the  ribs  ;  attempting  to  kick  may  fracture  the  femur ; 
saving  one's  self  from  falling  backward  may  fracture  the 
patella ;  throwing  a  stone  may  fracture  the  humerus ;  and 
sudden  extension  of  the  forearm  may  fracture  the  olecranon 
process  of  the  ulna. 

Predisposing-  Causes. — There  are  two  classes  of  predis- 
posing causes,  namely:  (i)  physiological,  natural  or  normal, 
and  (2)  pathological  or  abnormal. 

Natural  Predisposing  Causes. — Under  this  head  is  consid- 
ered the  liability  to  fracture  possessed  by  individual  bones 
because  of  their  shape,  structure,  function,  or  position.  Those 
predispositions  occasioned  by  special  ages  are  also  consid- 
ered. In  youth  epiphyseal  separation  is  commoner  than  fract- 
ure, and  a  fracture  is  apt  to  be  incomplete.  Fractures  are 
commonest  between  the  ages  of  twenty-five  and  sixty.  From 
two  to  four  years  of  age  a  child  is  more  liable  to  fracture  than 
later,  because  he  is  then  learning  to  walk  (Malgaigne).  The 
bones  of  the  old  are  easily  broken,  but  the  normal  lack  of 
activity  of  the  aged  saves  them  from  more  frequent  injury. 


^.---XAUSES   OF  FRACTURE.  409 

Thus  the  predispositions  of  age  are  in  part  due  to  habits  and 
in  part  to  bony  structure.  The  bones  of  the  young,  being 
clastic,  bend  considerably  before  they  break ;  the  bones  of 
the  old,  being  brittle  and  inelastic,  break  easily,  but  do  not 
bend,  in  old  age  the  bones  become  lighter  and  more  porous, 
though  they  do  not  diminish  in  size.  An  absorption  takes 
place' from  the  interior  of  a  bone,  particularly  at  its  articular 
head,  the  medullary  canal  increases  in  size,  the  cancellous 
spaces  become  notably  larger,  and  portions  of  the  remaining 
bone  of  the  interior  show  a  fatty  change.  There  is  no  in- 
crease in  the  amount  of  mineral  salts  present,  as  was  long 
taught.  These  alterations  occur  earlier  in  women  than  in 
men.^  The  change  of  age  is  a  diminution  in  the  amount  of 
bone  present,  and  sometimes  a  fatty  change  in  a  portion  of 
what  remains.  If  the  atrophy  of  bone  is  other  than  that 
normal  to  senility,  it  constitutes  a  pathological  predisposing 
cause  of  fracture.  Normal  predisposing  causes  include  the 
person's  weight  (which  determines  the  force  of  a  fall),  mus- 
cular development,  habits,  sex,  occupation,  and  the  season 
of  the  year.  .  .     . 

Pathological  Predisposing  Causes.— Hereditary  fragility  is 
a  condition  commonest  among  women,  often  existing  ni 
generation  after  generation,  and  in  this  condition  fractures 
occur  from  a  very  slight  force.  There  exists  in  these  cases 
bony  rarefaction — in  fact,  a  premature  senility. 

Nervous  Diseases. — Bony  nutrition  is  dependent  on  the 
spinal  cord,  and  the  trophic  influence  is  probably  exerted 
through  the  posterior  nerve-roots  (Gowers).  In  diseases  of 
the  anterior  cornua  bony  growth  is  much  interfered  with ; 
in  diseases  of  the  posterior  columns,  as  in  locomotor  ataxia, 
a  true  bony  atrophy  bespeaks  trophic  disorder.  Syringo- 
myelia causes  brittleness  of  the  osseous  structures,  and  m 
paralysis  agitans  bones  are  thought  to  break  easily.  Trophic 
changes  may  occur  in  the  bones  of  the  insane,  most  com- 
monly when  insanity  is  linked  to  organic  disease.  About 
one-quarter  of  paretic  dements  show^  undue  brittleness  or 
unnatural  softness  of  bones.^  The  bones  of  maniacs  are  fre- 
quently fragile.  Fractures  among  the  insane  are  not  neces- 
sarily an  indication  of  abuse. 

Rickets.— KxcVqX.?,  predisposes  to  fracture  because  of  altered 
bone-structure  and  the  great  liability  to  falls. 

Atrophy  of  Bone.— T\\is  condition,  as  has  been  seen 
(p.  389), 'is  normal  in  senility.  It  may  arise  from  want  of 
use,  as  is  observed  in  the    bedfast,  in  the  wasted  femur  of 

1  Humphrey  on  Old  Age.  ^  Manual  of  Insanity,  by  Spitzka. 


410   DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS. 

hip-joint  disease,  and  in  the  bones  of  a  stump.  It  may- 
arise  from  pressure,  as  when  an  aneurysm  compresses  the 
ribs,  sternum,  or  vertebrae.  Among  other  of  the  patho- 
logical predisposing  causes  are  to  be  mentioned  cancer, 
sarcoma,  hydatid  and  solitary  cysts  of  bone,  caries,  necrosis, 
gout,  scrofula,  syphilis,  mollities  ossium,  and  scurvy. 

Symptoms  of  Fracture. — History  of  an  Injury. — In 
spontaneous  fracture  there  may  be  no  record  of  violence ; 
for  instance,  a  bone  may  break  while  an  individual  is  turning 
in  bed.  In  investigating  the  history,  not  only  seek  for  a 
record  or  for  evidences  of  violence,  but  try  to  determine 
exactly  how  the  accident  happened. 

A  sound  of  cracking  is  occasionally  audible  to  a  bystander 
at  the  time  of  the  injury.  The  patient  may  have  heard  it, 
but  very  rarely  does.  A  rupture  of  a  tendon  or  a  ligament 
produces  a  similar  sound. 

Pain  is  usually,  but  not  invariably,  present  (absent  often  in 
rickets).  Malgaigne  says  that  in  some  fractures  the  pain  is 
sHght  or  absent,  in  others  it  is  torturing,  and  in  most  it  is 
severe  for  a  time  after  the  injury,  but  gradually  abates  unless 
reinduced  by  movement.  Pain  developed  at  the  time  of  the 
accident  is  far  less  important  as  a  .symptom  than  that  which 
can  subsequently  be  produced  by  movement.  In  indirect 
fracture  there  is  an  area  of  pain  at  the  point  of  application 
of  the  force,  and  another  at  the  seat  of  fracture.  Pain  at  the 
seat  of  fracture  can  be  greatly  aggravated  by  pressure  or 
movement  and  is  rather  narrowly  localized. 

Deformity  or  alteration  in  length  or  outline  is  due  in  part 
to  swelling  and  in  part  to  a  change  in  the  mutual  relation  of 
the  fragments  (displacement).  The  deformity  due  to  swelling 
is  no  aid  to  diagnosis,  as  the  same  condition  occurs  in  contu- 
sion, and  often  hides  some  positive  symptomatic  distortion. 
The  swelling  is  due  first  to  blood  and  next  to  inflammatory 
products  and  pressure-edema,  and  is  very  great  in  joint-fract- 
ures. The  deformity  of  displacement  may  be  produced  by 
the  violence  of  the  injury  (as  is  the  depression  in  a  skull- 
fracture),  by  the  weight  of  an  extremity  (as  is  the  falling  of 
the  shoulder  in  a  fracture  of  the  clavicle),  or  by  muscular 
action  (as  is  the  pulling  upward  of  the  superior  fragment  of 
a  fractured  olecranon  process). 

The  varieties   of  displacement  are  (i)  transverse  or 

lateral,  where  one  fragment  goes  to  the  side,  front,  or  back, 

but  does  not  overlap  the  other ;  (2)  angular,  the  bony  axis 

at  the  point  of  fracture   being    altered    and    the    fragments 

V  forming  with  each  other  an  angle ;  (3)  rotary,  one  fragment 


VARIETIES   OF  DISPLACEMENT   OF  FRACTCRES.       4I  I 

rotating  in  the  bony  circumference,  the  other  remaining 
stationary.  As  a  rule,  it  is  the  lower  fragment  which  turns 
on  its  long  axis,  the  limb  below  the  level  of  the  break  rotat- 
ing with  it ;  (4)  overlapping  or  overriding,  when  the  upper 
level  of  one  fragment  is  above  the  lower  level  of  the  other 
fragment.  It  is  usually  the  lower  fragment  which  is  drawn 
by  the  muscles  above  the  upper,  but  in  a  fracture  of  the 
lower  extremity  the  body-weight  and  sliding  down  in  bed 
may  push  the  upper  below  the  lower  fragment.  In  over- 
riding the  ends  are  near  together  and  the  bones  are  usu- 
ally in  contact  at  their  periphery.  It  is  obvious  that 
overlapping  is  associated  with  transverse  displacement,  as 
one  fragment  must  go  front,  back,  or  to  the  side  ;  (5)  pciic- 
tratiou  or  impaction  is  when  one  fragment  is  driven  into  the 
other,  thus  producing  shortening ;  (6)  separation  of  the  two 
fragments  occurs  in  fracture  of  the  patella,  olecranon,  os 
calcis,  certain  articulations,  and  in  some  breaks  of  the  hume- 
rus when  the  arm  is  not  supported. 

It  is  important  to  remember  that  a  dislocation  as  well  as  a 
fracture  may  produce  displacement,  but  these  two  conditions 
may  be  differentiated  by  the  observation  that  the  displace- 
ment of  fracture  tends  to  reappear  even  after  complete  reduc- 
tion, Avhile  the  displacement  of  dislocation  does  not  reappear 
after  correction.  A  displacement  is  difficult  of  detection  in 
a  flat  bone  and  when  one  of  two  parallel  bones  is  broken. 

Loss  of  function  may  be  shown  by  inability  to  move  the 
limb  because  of  the  break,  but  it  is  not  always  markedly 
present,  though  some  degree  invariably  exists.  It  is  slight 
in  "  green-stick  "  and  impacted  fractures  (unless  the  loss  of 
power  arises  from  pain  or  nerve-injury).  A  person  can  walk 
when  the  fibula  alone  is  broken,  and  likewise  in  some  cases 
of  intracapsular  fracture  of  the  femur,  and  can  often  put  the 
hand  on  the  head  in  fractured  clavicle  (Malgaigne).  The 
pain  of  any  injury  or  the  loss  of  power  from  nerx'e-trauma- 
tism  may  cause  loss  of  movement  in  the  limb.  This  symp- 
tom is  of  slight  diagnostic  value  in  most  fractures. 

Extravasation  of  Blood. — A  contusion  of  the  surface  ac- 
companied by  skin-abrasion  indicaties  merely  the  point  of 
application  of  direct  external  violence.  If  contusion  is  exten- 
sive over  a  superficial  bone,  as  the  tibia  or  parietal,  after 
a  few  hours  it  often  stimulates  fracture  by  presenting  a  soft, 
compressible  center  surrounded  by  a  ring  of  hard,  condensed 
tissues  and  coagulated  blood.  Direct  external  violence  may 
merely  occasion  ecchj-mosis,  and  in  fracture  from  indirect 
force  ecchymosis  may  occur  throughout  a  considerable  area. 


412   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

In  regard  to  this  symptom,  note  that  even  great  external 
violence  may  occasion  no  evident  contusion  or  ecchymosis, 
and  in  any  fracture  this  symptom  may  be  present  or  absent. 
In  old  people,  anemic  subjects,  alcoholics  and  opium-eaters, 
extravasation  of  blood  is  frequently  marked  and  persistent. 
By  suggillation  is  meant  an  extravasation  of  blood  which 
slowly  invades  wide  areas  of  tissue  and  which  appears  at  the 
surface  only  after  some  time,  and  then  usually  as  a  yellowish 
discoloration,  red  hemoglobin  having  been  changed  to  yellow 
hematoidin.  Linear  ecchymosis  has  been  esteemed  by  some 
as  a  sign  of  fissure,  and  it  is  often  noted  after  fracture  of  the 
fibula.  Linear  ecchymosis  over  the  line  of  the  posterior 
auricular  artery  was  shown  by  Battle  to  be  a  valuable  sign  of 
fracture  of  the  posterior  fossa  of  the  base  of  the  cranium. 

Preternatural  mobility  is  a  most  important  symptom,  which 
is  pathognomonic  when  surely  found.  The  unbroken  bone 
is  nowhere  mobile  in  continuity.  By  preternatural  mobility 
is  meant  that  a  bone  is  mobile  in  continuity  or  that  there  is 
abnormality  in  the  direction  or  extent  of  joint-mobility.  In 
some  fractures  this  symptom  does  not  exist  (impacted,  green- 
stick,  and  locked  serrated  fractures) ;  in  others  it  cannot 
be  found  (fractures  of  tarsus,  carpus,  vertebral  bodies) ;  in 
others  it  is  difificult  to  obtain,  but  at  times  can  be  developed 
(fractures  near  or  into  many  joints).  To  develop  this  symp- 
tom, try,  when  the  case  admits,  to  grasp  the  fragments  and 
to  move  them  in  opposite  directions.  In  a  fracture  of  the 
shaft  of  the  femur  or  humerus  fix  the  upper  fragment  and  carry 
the  knee  or  elbow  in  various  directions  to  develop  bending  at 
the  point  of  fracture.  In  fracture  of  the  clavicle  push  the 
shoulder  downward  and  inward.  In  fractures  of  either  bone  of 
the  forearm  grasp  the  opposite  bone  with  four  fingers  of  each 
hand  and  make  pressure  on  the  suspected  bone  alternately 
with  either  thumb,  and  the  same  procedure  can  be  used  in 
fractures  of  the  leg.  In  fracture  of  the  neck  of  the  femur 
note  the  rotation-arc  of  the  great  trochanter  (Desault).  In 
fracture  of  the  lower  end  of  the  radius  bend  the  hand  back, 
and  in  a  break  of  the  lower  end  of  the  fibula  evert  the  foot 
(Maisonneuve).  In  seeking  preternatural  mobility,  remember 
that  the  elastic  ribs  when  being  forced  in  give  a  sense  of  bend- 
ing, and  that  the  fibula  at  its  middle  is  "  normally  flexible  " 
(Dupuytren).     Some  rachitic  bones  may  be  bent. 

Crepitus  or  crepitation  is  both  a  sensation  and  a  sound, 
which  indicates  the  grating  together  of  the  two  rough  sur- 
faces of  a  broken  bone.  This  symptom  is  of  great  value, 
but  it  is  not  always  present.     It  is  absent  in  locked  serrated 


DIAGNOSIS   OF  FRACTURES.  413 

fractures,  in  impacted  fractures,  in  cases  where  the  broken 
ends  cannot  be  approximated  (as  in  overlapping),  is  rare 
when  a  fractured  surface  is  against  the  side,  and  not  the 
broken  face,  of  the  other  fragment,  and  is  unusual  in  incom- 
plete fractures.  Crepitus  is  often  absent  in  epiphyseal  sepa- 
ration, in  softened  bones,  and  in  fractures  in  or  near  joints, 
and  it  may  be  prevented  from  occurring  by  blood-clot,  fascia, 
or  muscle  between  the  broken  surfaces.  The  grating  found 
in  tenosynovitis  must  not  be  mistaken  for  the  crepitus  of  fract- 
ure :  the  former  is  diffuse,  large,  soft,  and  moist ;  the  latter 
is  limited,  small,  harsh,  and  dry.  The  clicking  of  an  inflamed 
or  eroded  joint  and  the  cracking  of  emphysema  must  also 
be  separated  from  bony  crepitus.  Crepitus  of  fracture  may 
be  present  at  one  moment,  but  absent  the  next.  It  is  often 
not  detected  during  the  time  swelling  is  marked,  and  cannot 
be  discovered  after  organization  of  the  callus  begins.  In  but 
few  fractures  is  it  needful  to  try  to  hear  crepitus  with  the 
naked  ear  or  with  a  stethoscope  upon  the  part,  but  in  doubt- 
ful cases  of  fractures  of  ribs  and  joints  this  evidence  should 
be  sought  for. 

The  above-named  symptoms  are  known  as  "  direct."  There 
are  other  symptoms  known  as  "  circumstantial,"  such  as  the 
flow  of  blood  and  cerebrospinal  fluid  from  the  ear  after 
some  fractures  of  the  middle  fossa  of  the  skull ;  emphysema 
of  the  face  and  epistaxis  after  fracture  of  the  nasal  bones ; 
hemoptysis  and  emphysema  after  crushes  of  the  chest ;  dis- 
coloration following  the  line  of  the  posterior  auricular  artery 
after  fracture  of  the  posterior  fossa  of  the  skull ;  and  sub- 
conjunctival ecchymosis  after  fracture  of  the  anterior  fossa 
of  the  skull. 

Diagnosis. — Examine  as  soon  as  practicable  after  the 
injury — before  the  onset  of  swelling,  if  possible.  Expose  the 
part  completely,  taking  off  the  clothing,  if  necessary,  b}'  clip- 
ping it  along  the  seams.  Attentively  scrutinize  the  part  and 
compare  it  with  the  corresponding  part  on  the  opposite  side. 
If  any  deformity  be  present,  it  must  be  ascertained  that  it 
did  not  exist  before  the  accident.  If  the  nature  of  the  in- 
jury be  uncertain,  if  the  patient  be  very  nervous,  or  if  the 
part  be  acutely  painful,  it  is  better  to  give  ether  to  diagnos- 
ticate, set  and  dress.  In  injuries  of  the  elbow-joint  always 
anesthetize  before  examination,  unless  an  x-ray  apparatus  is 
accessible  to  settle  the  diagnosis,  and  even  then  it  is  usu- 
ally well  to  anesthetize  in  order  to  facilitate  reduction  and 
dressing. 

A  fracture  is  distinguished  from  a  dislocation  by  its  preter- 


414    DISEASES  AND   INJiJRIES   OF  BONES  AND  JOINTS. 

natural  mobility,  its  easily  reduced  but  recurring  displace- 
ment, and  its  crepitus,  as  against  the  preternatural  rigidity, 
the  deformity,  difficult  to  reduce,  but  remaining  reduced,  and 
the  absence  of  crepitus  of  a  dislocation.  Further,  in  disloca- 
tion the  bone,  when  rotated,  moves  as  one  piece,  whereas  in 
fracture  it  does  not  so  move ;  in  dislocation  the  bony  proc- 
esses are  felt  occupying  their  proper  relations  to  the  rest  of 
the  same  bone,  while  in  fracture  some  of  them  present  altered 
relations  ;  in  dislocation  the  head  of  the  bone  is  found  out  of 
its  socket,  but  in  fracture  it  is  felt  in  its  place.  It  is  impor- 
tant to  remember,  moreover,  that  a  fracture  and  a  dislocation 
may  occur  together,  and  that  the  rubbing  of  a  dislocated 
bone  against  an  articular  edge,  when  the  joint  has  been 
roughened  by  inflammation,  simulates  crepitus. 

Great  contusion,  by  inducing  extreme  tumefaction,  may 
mask  characteristic  deformity  and  obscure  crepitus.  When 
only  a  contusion  exists  pain  is  apt  to  be  widespread;  but  if  a 
fracture  has  occurred,  the  pain  is  accentuated  at  some  narrow 
spot.  In  many  cases,  before  he  can  give  a  certain  opinion, 
the  surgeon  must  wait  some  days  until  the  swelling  has 
largely  subsided.  In  such  a  case  it  is  best  to  assume  in  our 
treatment  that  a  fracture  exists  until  the  contrary  is  known. 
Combat  swelling  by  rest,  the  use  of  evaporating  lotions,  and 
moderate  compression. 

In  impaction  the  diagnosis  is  difficult.  The  moderate  de- 
formity is  concealed  by  swelling ;  crepitus  and  preternatural 
mobility  do  not  exist  unless  the  fragments  are  pulled  apart, 
and  there  is  not  necessarily  much  loss  of  function.  A  con- 
clusion is  reached  largely  by  considering  the  nature,  direc- 
tion, and  extent  of  the  violence,  the  seat  of  the  pain,  and  by 
a  careful  study  of  the  most  minute  deformity.  It  is  difficult 
to  recognize  fissures.  They  rarely  present  any  evidence  of 
their  existence  except  a  localized  pain,  and  possibly  a  linear 
ecchymosis  appearing  after  a  few  days. 

In  green-stick  fractures  the  age,  the  deformity,  and  possi- 
bly crepitus  during  reduction  help  in  the  diagnosis.  Epiphy- 
seal separations  are  diagnosticated  by  the  age,  the  preternat- 
ural mobility,  the  deformity,  the  situation  of  the  injury,  and 
the  absence  of  crepitus  or  the  presence  only  of  a  soft  crepitus. 
Fractures  are  often  difficult  to  recognize  when  occurring  in  a 
group  of  bones  like  those  of  the  carpus  and  tarsus  (which 
are  firmly  joined  by  dense  ligaments)  or  in  one  of  two  paral- 
lel bones.  There  is  not  always  a  certainty  that  a  fracture 
exists,  and  when,  after  a  careful  examination,  there  is  still  an 
uncertainity,  do  not  prolong  the  efforts  or  use  great  force,  but 


REPAIR    OF  FRACTURES.  4^5 

treat  the  case  as  a  fracture  until  a  cure  ensues  or  the  diag- 
nosis becomes  apparent. 

We  have  recently  had  added  to  our  resources  a  method 
of  incalculable  value  in  diagnosticating  fracture ;  that  is,  the 
use  of  the  force  known  as  the  x-ray  or  the  Rdntgen  ray.     We 
can  look  through  a  part  with  a  fluoroscope  and  see  the  bones 
as  shadows,  or  we  can  take  a  negative  of  the  shadows  and 
print  skiagraphs  from  it.     This  method  is  applicable  even 
when  the  parts  are  swollen,  and  even  when  a  limb  is  clothed 
or  wrapped  in  dressings.     It  is  possible  to  obtain  a  picture  of 
a  fractured  skull  after  long  exposure  ;  fractured  ribs  and  ver- 
tebrJE  can  be  detected ;  and  the  process  is  of  the  greatest 
use  in  detecting  fractures  of  the  limbs.     In  order  to  obtain 
certain  results  the  x-rays  must  be  used  by  an  expert.      This 
method  should,  if  possible,  be  resorted  to  in  doubtful  cases. 
Complications  and  Consequences. — Some  of  the  con- 
sequences and  complications  of  fractures  are — sloughing  of 
the  soft  parts,  thus  making  the  fracture  compound ;  extrav- 
asation of  blood,  causing  swelling  or  even  gangrene  ;  rupt- 
ure of  the  main    artery    or  vein  of  the    limb ;  dislocation  ; 
edema  from  pressure  of  extravasated  blood,  from  inflamma- 
tory exudation,  from  tight  bandaging,  from  thrombosis,^  or, 
later,    from    the  pressure  of  callus ;  stiffness  of  joints  from 
synovitis  with  adhesion,  from  displaced  fragments,  or  from 
intra-articular  callus  ;  stiffness  of  tendons  from  adhesive  the- 
citis  or  from  the  pressure  of  callus  ;  paralysis  from  traumatic 
neuritis  or  the  pressure  of  callus  upon  nerve-trunks  ;  muscu- 
lar spasm  ;  painful  callus  ;  exuberant  callus  ;  embolism  ;  fat- 
embolism  ;  pulmonary  congestion  ;  gangrene  ;  shock  ;  septi- 
cemia ;  pvemia;  tetanus;  dehrium  tremens;  urinary    reten- 
tion ;  extensive  laceration  of  the  soft  parts  ;  rupture  of  large 
nerves  ;  and  involvement  of  joints. 

Repair  of  Fractures.— Simple  Fracture.— In  a  smiple 
fracture  the  bone  is  broken,  the  medullary  contents  are  lacer- 
ated, the  periosteum  is  torn,  and  the  overlying  soft  parts  are 
damaged  to  a  considerable  degree.  The  periosteum  is 
stripped  more  or  less  from  each  fragment,  but  it  is  rarely 
completely  torn  through,  an  untorn  portion  known  as  the 
periosteal  bridge  remaining.  The  amount  of  blood  effused 
is  usually  considerable,  and  it  forms  a  decided  prominence  at 
the  seat  of  fracture  ;  it  gradually  gathers  because  of  oozmg. 
and  soon  clots.  This  clot  Hes  in  the  medullary  canal,  be- 
tween the  fragments,  under  the  periosteum  at  the  ends  of  the 
fragments,  and  in  the  tissues  outside  of  the  periosteum. 
Very  rapidly  after  the  accident  the  damaged  parts  mflame 


4l6  DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

(bone,  endosteum,  periosteum,  and  other  periosseous  struct- 
ures). The  inflammatory  exudate  enters  into  the  blood- 
clot  and  the  leukocytes  eat  up  and  destroy  the  clot.  The 
clot  is  simply  dead  material  and  in  no  way  contributes  to 
repair.  The  cells  of  the  damaged  tissue  proliferate  and  the 
young  proliferating  cells  (embryonic  tissue)  enter  into  the 
spaces  in  the  blood  and  clot  eaten  out  by  the  leukocytes. 
F"inally  the  entire  clot  is  replaced  by  embryonic  tissue, 
which  quickly  becomes  vascularized  (granulation-tissue). 

Granulation-tissue  is  changed  into  fibrous  tissue  and  then 
into  bone,  only  the  tissue  springing  from  the  periosteal 
bridge  going  through  a  cartilaginous  stage.  The  mass  of 
new  tissue  around  and  between  the  bone-ends  is  called 
callus.  It  will  be  observed  that  the  name  is  applied  succes- 
sively to  embryonic  tissue,  granulation-tissue,  fibrous  tissue, 
and  bone.  Warren  tells  us  that  callus  has  no  well-defined 
outline,  and  "  involves  not  only  the  bone  and  periosteum,  but 
also  the  connective  tissue  and  some  of  the  surrounding  mus- 
cular tissue."  Within  a  few  days  after  the  injury  the  inflam- 
matory mass  is  much  firmer  than  follows  inflammation  in- 
volving other  structures,  and  the  bone-ends  are  deeply  im- 
bedded in  a  dense  mass. 

During  the  second  week  the  callus  is  greatly  strengthened 
by  the  formation  of  dense  fibrous  tissue  in  and  below  the 
periosteum,  of  less  dense  fibrous  tissue  outside  of  the  peri- 
osteum, and  of  cartilage  from  the  periosteal  bridge.  The 
newly  formed  tissue  contracts  decidedly.  During  the  third 
week  ossification  begins  at  the  points  farthest  from  the  fract- 
ure, and  in  the  course  of  a  short  time  (from  three  to  six 
weeks)  is  complete.  The  mass  of  ossified  callus,  or  new 
bone,  is  spindle-shaped  and  spongy. 

The  term  intermediate,  definitive,  or  permanent  callus  is 
used  to  describe  the  material  which  forms  between  the  fract- 
ured ends.  The  name  provisional  or  temporary  callus  is 
given  to  the  material  within  the  canal  (central  callus)  and 
external  to  the  bone  (ensheathing  callus).  The  amount  of 
provisional  callus  depends  directly  on  the  extent  of  separa- 
tion and  the  amount  of  motion  between  the  fragments.  It  is 
Nature's  splint,  and  when  the  break  is  not  well  immobilized  a 
large  amount  is  formed.  The  greater  the  amount  of  motion, 
short  of  a  degree  sufficient  to  cause  non-union,  the  larger  the 
amount  of  provisional  callus. 

The  ensheathing  callus  is  after  a  time  largely  absorbed, 
and  the  central  callus  in  the  course  of  a  long  time  may  also 
be  absorbed,  with  the    restoration  of  the    medullary  canal. 


NO  N- UN  TON  OF  FRACTURES.  417 

although  this  latter  result  is  rare.  An  excessive  amount  of 
provisional  callus  may  ossify  nearby  tendons,  may  unite  two 
parallel  bones  (radius  to  ulna — tibia  to  fibula — a  rib  to  its 
neighbors),  may  block  a  joint  just  as  a  stone  in  the  crack  of 
a  door  will  block  a  door,  or  may  absolutely  abolish  a  joint. 
Fragments,  even  if  entirely  detached,  often  unite,  but  they 
may  be  surrounded  by  provisional  callus  ;  sometimes  they  do 
not  cause  trouble,  but  sometimes  suppuration  takes  plaice. 
It  takes  about  one  year  for  Nature  to  remove  the  temporary 
callus.  The  definitive  or  permanent  callus  after  a  time  ceases 
to  be  porous  and  becomes  very  dense  bone.  If  callus  does 
not  pass  beyond  the  fibrous  state,  there  exists  that  form  of 
ununited  fracture  known  as  "  fibrous  union." 

Compound  fractures  without  much  destruction  or  bruis- 
ing of  soft  parts,  if  treated  antiseptically,  become  at  once 
simple  fractures  and  unite  as  such.  If  the  wound  is  not 
drained  and  asepticized  and  septic  inflammation  occurs,  pus 
forms,  and  union  by  granulation  is  the  best  that  can  be 
obtained.  Compound  fractures  by  direct  violence  will  not 
heal  by  first  intention  because  of  the  extensive  loss  of 
vitality  of  a  large  area  of  the  soft  parts. 

Delayed  union  may  be  due  to  ill-health,  want  of  ap- 
proximation, etc.  (any  of  the  causes  mentioned  under  Non- 
union).    It  is  not  non-union,  but  may  eventuate  in  non-union. 

Non-union  of  Fractures. — An  ununited  fracture  is  a 
fracture  in  which  union  is  not  effected  at  all  or  in  which  it  is 
not  brought  about  by  bone.  The  causes  are  local  and  con- 
stitutional. The  local  causes  are  ( i)  want  of  approximation  of 
fragments  (a  frequent  cause  of  want  of  approximation  is  inter- 
position of  soft  tissues,  especially  muscle) ;  (2)  want  of  rest ;  (3) 
want  of  blood-supply  (as  seen  in  the  heads  of  humerus  and 
femur,  or  when  a  nutrient  artery  is  torn,  or  when  a  thrombus 
forms  in  a  vein  near  the  fracture) ;  (4)  defective  innervation  ;  and 
(5)  bone-disease.  The  constitutional  causes  are  debility,  scurvy, 
Bright's  disease,  syphilis,  etc.  In  this  condition  the  broken 
ends  of  the  bone  round  off  and  the  medullary  canal  in  each 
fragment  becomes  closed  by  bone.  The  fragments  may  not 
be  held  together  by  any  material,  or  they  may  be  held  by  very 
thin  and  much-stretched  fibrous  tissue  {vieinbranous  union), 
or  by  strong,  thick,  fibrous  tissue  [liganieutoiis  or  fibrous 
union).  When  the  ends  of  the  bones  come  together,  are 
held  by  a  fibrous  capsule,  and  move  on  each  other,  there 
exists  dL  false  joint  or  pseudarthrosis.  Such  a  joint  may  after 
a  time  secrete  serous  fluid  for  lubrication. 

Vicious  union  is  union  with  great  deformity,  and  is  often 

27 


41 8   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

productive  of  pain  and  loss  of  function.  It  arises  from  failure 
to  coaptate  the  fragments,  from  a  recurrence  of  displacement 
after  reduction,  or  from  yielding  of  callus  after  the  removal 
of  splints. 

Treatment  of  Fractures. — If  a  man  is  found  in  the 
street  with  a  fracture,  further  injury  must  be  prevented  by 
applying,  after  cutting  off  the  clothing  over  the  fracture,  some 
temporaiy  support.  If  an  ambulance  or  patrol-wagon  can- 
not be  obtained,  move  the  patient  by  hand.  If  the  lower  ex- 
tremity be  involved,  an  improvised  stretcher  (a  board  or  a 
shutter)  is  placed  on  the  ground  beside  the  patient,  who  is 
placed  on  the  stretcher,  the  surgeon  lifting  the  injured  limb, 
and  the  patient  is  then  carried  to  the  hospital  and  carefully 
transferred  to  a  fracture-bed,  or,  if  taken  home,  to  a  small 
ordinary  bed,  a  board  being  placed  beneath  a  rather  hard  but 
even  mattress.  The  temporary  appliances  are  now  removed 
and  a  diagnosis  by  the  methods  before  given  is  proceeded  with. 
After  determining  the  nature  of  the  injury  the  fragments  must 
be  adjusted.  This  should,  if  possible,  be  done  at  once,  because 
a  fracture  remaining  unreduced  may  become  compound,  the 
fragments  may  injure  important  structures,  and  they  are  sure 
to  cause  intense  pain.  Reduction  is  easily  effected  during 
shock,  as  the  muscles  are  in  a  state  of  relaxation.  If  there 
is  great  swelling,  reduction  may  be  impossible,  and  the  part 
must  then  be  supported  and  moderate  cold,  sorbefacients, 
and  gentle  pressure  used,  avoiding  ice  and  tight  band- 
aging, which  predispose  to  gangrene.  Set  the  fracture  at 
the  first  possible  moment.  Velpeau's  axiom  was  to  reduce 
fractures  at  once,  regardless  of  pain,  spasm,  or  inflammation, 
as  reduction  is  their  cure. 

If  the  patient  is  very  nervous,  if  the  pain  is  severe,  or  if 
rigid  muscles  antagonize  the  efforts,  then  reduce  the  fracture 
under  anesthesia.  In  some  fractures  (as  those  of  the  clavicle) 
adjustment  is  effected  by  altering  the  position,  and  in  others 
(as  those  of  the  femur)  by  extension  and  counterextension ; 
in  some  by  tenotomy,  and  in  some  by  kneading,  bending, 
and  coaptation.  When  extension  is  employed,  always  en- 
deavor to  get  a  point  of  counterextension.  The  extension 
is  to  be  made  on  the  broken  bone  (if  possible,  in  the  axis  of 
the  bone),  is  to  be  steady,  and  neither  jerky  nor  violent.  In 
some  cases  complete  reduction  is  impossible.  This  may  be 
due  to  spasm,  to  swelling,  to  the  catching  of  soft  parts 
between  the  fragfrnents,  to  the  existence  of  a  loose  fragment, 
to  locking,  or  to  impaction.  An  impaction  by  rotation  can 
generally  be   released,  but   it   is    sometimes    undesirable    to 


TREATMENT  OF  FRACTURES.  419 

reduce  it.  If  the  fragments  cannot  be  adjusted  without 
violence,  retain  them  in  the  best  attainable  position,  combat 
the  antagonistic  cause,  and  set  them  properly  as  soon  as 
possible. 

After  adjusting  the  fragments  they  must  be  maintained 
in  position  by  some  retentive  apparatus.  Avoid  pressure 
over  joints  or  bony  prominences,  and  particularly  guard 
against  tight  or  improper  bandaging.  The  circulation  in 
the  fingers  or  the  toes  must  be  observed  as  an  index  of 
circulation  in  the  limb ;  hence  leave  those  digits  exposed. 
A  retentive  apparatus  should  prevent  the  re-occurrence  of  de- 
formity, and  not  be  itself  productive  of  pain  or  harm.  For 
the  first  few  days  of  treatment  of  a  simple  fracture  the  dress- 
ing is  removed  every  day,  to  make  sure  that  deformity  has  not 
recurred,  and  if  it  does  recur  the  fragments  must  at  once  be 
reset.  The  splints  should  be  padded  thoroughly,  especially 
when  over  joints  or  bony  prominences,  and  they  should,  if 
possible,  fix  the  joints  immediately  above  and  below  the 
break.     A  primary  roller  should  never  be  used. 

Some  surgeons  at  once  apply  an  immovable  dressing. 
This  proceeding  is  safe  in  simple  fractures  without  much 
displacement  or  soft-part  injury.  This  dressing  is  valuable 
in  military  practice,  for  the  old  and  feeble  whom  we  fear 
to  put  to  bed,  for  the  young  who  are  very  restless,  and 
for  the  insane  or  the  delirious.  If,  however,  there  is  great 
deformity,  much  soft-part  injury,  or  marked  swelling,  im- 
movable dressings  may  induce  sloughing,  edema,  gangrene, 
or  fault\^  union.  In  the  above-named  cases  use  splints  for 
the  first  few  days  ;  then,  if  it  is  desirable,  the  immovable 
dressing  can  be  applied.  It  is  dangerous  to  keep  old  or 
feeble  persons  long  in  bed,  as  they  are  prone  to  develop 
bed-sores  and  hypostatic  pulmonary  congestion.  The  period 
for  the  artificial  retention  of  the  fracture  varies  with  the  seat 
of  the  fracture  and  the  age  and  the  condition  of  the  patient. 
Passive  motion  is  to  be  made  in  most  fractures  in  from  two  to 
three  weeks,  though  it  is  sometimes  made  earlier  to  prevent 
ankylosis.  Landerer  strongly  advocates  massage,  believing 
that  it  hastens  union  and  prevents  wasting.  He  applies  it  as 
soon  as  there  is  no  danger  of  the  callus  bending  (in  from 
eight  to  fourteen  days).  Massage  should  not  be  used  when 
great  edema  points  to  the  possibility  of  venous  thrombosis. 
The  movements  might  break  up  a  clot  and  cause  fatal  em- 
bolism.^ Ver>'  early  massage  may  cause  fat-embolism.  In 
fracture  of  the  patella.  Barker  and  many  others  believe  in 

1  Cerne's  case,  in  N'onnandie  me  J.  ;   Bull,  med.,  1895,  No.  44. 


420   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

wiring,  and  some  surgeons  advocate  the  same  procedure  in 
fracture  of  the  clavicle  and  fracture  of  the  tibia. 

The  plan  known  as  the  ambulator}^  treatment  of  fractures 
of  the  lower  extremities  has  many  advocates.  Its  aim  is 
not  only  to  get  the  patient  about  on  crutches,  but  also  to 
cause  him  to  use  the  limb.  It  is  held  that  this  plan  of  treat- 
ment greatly  lessens  the  patient's  sufferings  and  actually 
favors  union  by  the  stimulation  of  walking.  Bardeleben, 
in  his  report  to  the  German  Surgical  Congress,  gave  the 
records  of  1 1 1  fractures  of  the  lower  extremity  thus  treated 
i^'j'j  simple  and  12  compound  fractures  of  the  leg;    17  simple 


Fig.  109. — Ambulatory  dressing  of  plaster-of- Paris      Fig.  iio. — Ambulatory  dressing  appa- 
for  fracture  of  the  bones  of  the  leg  (Pilcher).  ratus  for  fracture  of  thigh  (Harting). 


and  5  compound  fractures  of  the  thigh).  The  patients  were 
gotten  about  a  few  days  after  the  accident,  were  able  to 
attend  to  business,  had  excellent  appetites,  digested  their 
food  perfectly,  slept  well,  and  were  saved  from  muscular 
atrophy.     Pilcher    has   warmly   advocated    the    method.     It 


TREATMENT  OF  FRACTURES.  42  I 

can  be  used  in  fractures  as  high  up  as  the  middle  of  the 
femur.  The  apparatus  which  we  should  employ  in  the  am- 
bulators-treatment reaches  below  the  sole  of  the  foot,  and  is 
supported  firmly  above  the  seat  of  fracture,  the  weight  of 
the  body  being  transferred  from  above  the  fracture  to  the 
firm  pad  below  the  sole  of  the  foot  on  which  the  patient 
walks  (Fig.  no).  This  appliance  in  a  fractured  thigh  is  put 
on  about  one  week  after  the  infliction  of  the  injury.  While 
the  patient  sits  on  the  ischial  tuberosities  extension  is  made 
upon  the  leg.  The  seat  of  fracture  is  encircled  with  a  thin 
plaster  cast.  The  sole  of  the  other  foot  is  raised  by  a  cork 
sole.  Albers  uses  plaster-of-Paris  strengthened  by  bits  of 
wood,  running  from  below  the  sole  of  the  foot  to  the  iliac 
crest,  when  he  treats  a  fractured  thigh.  Krause  says  in 
fracture  of  the  ankle  carry  the  dressing  to  the  head  of  the 
tibia;  in  fracture  of  the  leg  carry  it  to  the  middle  of  the 
thigh ;  in  fracture  of  the  lower  end  of  the  femur  carry  it  to 
the^pelvis.^  Bradford  warmly  advocates  the  use  of  Thomas's 
splint  often  combined  with  plaster-of-Paris. 

Prevention  and  Treatment  of  Complications. — In  every 
case  of  fracture  feel  for  the  pulse  below  the  injury  in  order 
to  be  sure  the  artery  is  not  ruptured.  If  the  soft  parts  are 
badly  contused,  tiy  to  prevent  sloughing  by  employing  rest, 
relaxation,  and  by  applying  heat.  If  superficial  sloughing 
occurs,  treat  antiseptically,  remembering  that  even  a  super- 
ficial excoriation  can  admit  bacteria  which,  carried  by  the 
blood  or  lymph,  may  infect  the  bones.  If  a  slough  leads 
down  to  the  fracture,  treat  the  case  as  one  of  compound 
fracture.  If  there  be  great  blood-extravasation,  the  danger 
is  gangrene,  and  the  foot  of  the  bed  is  to  be  elevated,  or  the 
extremit>%  to  which  splints  and  bandages  are  to  be  loosely 
applied,  is  to  be  raised  and  surrounded  with  hot  bottles.  If 
a  bleb  forms,  it  is  to  be  opened  with  a  needle  and  dressed 
antiseptically.  If  gangrene  occurs,  treat  by  the  usual  rules. 
Frequently  after  fracture  of  a  bone  blebs  containing  reddish 
serum  form  on  the  skin.  The  appearance  of  blebs  when  the 
circulation  is  good  does  not  mean  gangrene,  and  is  not  of 
any  particular  consequence.  If  blebs  are  due  to  gangrene, 
there  are  distinct  symptoms  of  circulatory  impairment. 

Edema  may  be  due  to  tight  bandaging.  If  it  is  due  to 
phlebitis,  there  is  danger  of  pulmonary  or  cerebral  embo- 
lism. In  phlebitis  elevate  the  limb,  remove  all  constnction, 
and  employ  locally  tincture  of  iodin  or  ichthyol  ointment ; 
do   not  use   massage,  and   give  stimulants   by  the  mouth. 

1  Centralbl.f.  Chir.,  vol.  xxii.,  1895. 


422    DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

In  edema  due  to  weak  circulation  or  venous  relaxation  use 
daily  frictions  and  firm  bandaging.  If  the  fracture  involves 
a  joint,  carefully  adjust  the  fragments,  make  passive  motion 


Fig.  III. — Fracture -hook  (McBurney  and  Dowd). 

early,  and   inform  the   patient  that   he  will  probably  have  a 
stiff  joint. 

A  dislocation  occurring  with  a  fracture  is  reduced  at   once 


Fig.  112.— Fracture-hook  applied  at  base  of  acromion  process  (McBurney  and  Dowd). 

if  possible.  To  do  this,  splint  the  limb  and  give  ether,  and 
try  to  reduce  while  the  limb  is  managed  with  the  splint  as  a 
handle.     Allis  is   often  able  to  reduce  a  dislocation  accom- 


FiG.  113.— Fracture-hook  inserted  in  displaced  fragment  (McBurney  and  Dowd). 

panied  by  a  fracture.  He  uses  the  untorn  portion  of  perios- 
teum as  a  hinge,  pulls  upon  the  fragment,  and  forces  it  in 
place  by  manipulation.     If  this  fails,  it  is  best  to  incise  and 


TREATMEXT  OF  FRACTURES.  423 

pull  the  separated  end  in  place  by  the  hook  of  McBurney  and 
Dowd  (Figs.  111-113);  but  some  surgeons  say,  get  the 
bones  in  the  best  possible  position,  set  them,  await  union, 
and  then  treat  the  unreduced  dislocation.  A  rupture  of  the 
main  arter\'  of  the  limb  presents  the  symptoms  of  absent 
pulse  below  the  rupture,  a  tumor  which  may  pulsate,  and 
possibh'  an  aneur^'smal  thrill  and  bruit.  This  condition  de- 
mands that  the  surgeon  should  apply  an  Esmarch  bandage, 
cut  down  upon  the  tumor,  turn  out  the  clot,  and  ligate  each 
end  of  the  vessel.  If  these  measures  fail  or  if  gangrene 
appears,  amputate  at  once  above  the  seat  of  the  fracture. 

Inflammation  is  to  be  treated  by  compression,  rest,  mod- 
erate cold,  and  later  by  a  50  per  cent,  ichthyol  ointment. 
IMuscular  spasm  requires  morphin  internally,  firm  bandaging, 
or  even  tenotom\'.  Fat-embolism  is  treated  by  stimulants 
and  inhalation  of  oxygen,  and  possibly  artificial  respiration. 
Shock,  delirium  tremens,  urinar}'  retention,  etc.,  are  treated 
according  to  the  ordinan.-  rules  of  surgen,-. 

Treatment  of  Com.pound  Fractures. — It  must  first  be 
decided,  in  a  case  of  compound  fracture  of  a  limb,  if  ampu- 
tation is  necessar}-,  and  the  ,i--ra}"s  are  of  great  value  in  de- 
termining the  condition  of  the  bones  in  a  crushed  part. 
Amputation  is  demanded  when  the  limb  is  completely 
crushed  or  pulpefied  through  its  entire  thickness ;  when 
extensive  pieces  of  skin  are  torn  off;  when  the  main  arter}^ 
vein,  and  ner\"e  are  torn  through ;  and  sometimes  when 
there  is  violent  hemorrhage  from  a  deep-seated  vessel ;  or 
when  an  important  joint  is  badly  splintered.  What  is  to 
be  done  is  to  some  extent  determined  b\-  the  patient's  age 
and  general  health.  In  a  healthy  young  person,  if  in  doubt, 
give  the  limb  the  benefit  of  the  doubt  and  try  to  save  it ;  if 
the  arter\-  or  vein  alone  is  ruptured,  cut  down  upon  it  and  tie 
both  ends;  if  the  ner\'e  is  severed,  suture  it;  if  a  joint  is 
opened,  drain  and  asepticize.  If  an  attempt  is  made  to  save 
the  limb,  be  ready  at  any  time  to  amputate  for  gangrene, 
secondary  hemorrhage  (if  re-ligation  at  original  point  and  com- 
pression high  up  fail).  extensi\-e  cellulitis,  and  profuse  and  pro- 
longed suppuration.^  When  it  is  determined  to  try  to  save  the 
limb,  the  part  must  be  cleansed  thoroughly  by  the  antiseptic 
method  (in  no  injuries  is  this  more  important).  If  a  small 
portion  of  bone  protrudes,  cleanse  the  skin  of  the  extremity 
and  the  protruding  bone,  push  the  spicule  out  a  httle  more 
and  cut  it  off.     If  a  large  piece  of  bone  is  protruded,  it  must 

1  See  Howard  Marsh  on  "  Fractures,"  in  Heath's  Dictionary  of  Practical 
Surgery. 


424   DISEASES  AND   INJURIES   OE  BONES  AND  JOINTS. 

not  be  cut  away,  but  should  be  thoroughly  disinfected,  and 
after  the  skin  wound  has  been  enlarged  should  be  returned 
into  place.  Hemorrhage  requires  a  free  incision  to  permit  of 
ligation  of  bleeding  points.  In  comminuted  fractures,  frag- 
ments which  arc  completely  broken  off  should  be  removed, 
but  those  which  are  only  partially  separated  should  be 
retained.  In  all  cases  a  drainage-tube  must  be  carried  down 
to  the  seat  of  fracture,  and  in  some  cases  a  counter-opening 
must  be  made  and  the  tube  be  pulled  through  the  limb 
(Fig.  114). 

After  inserting  the  tube  the  wound  is  sutured,  a  plentiful 
antiseptic  dressing  is  applied,  and  the  extremity  is  dressed 


Fig.  114. — Fenestrated  plaster-of-Paris  dressing 


with  plaster.  The  plaster  can  be  applied  over  a  narrow 
strip  of  wood,  trap-doors  being  cut  in  the  plaster  before  it 
sets  (Fig.  114).  A  trap-door  is  cut  over  each  end  of  the 
drainage-tube,  and  they  are  covered  with  gauze  and  a  ban- 
dage. 

The  bracketed  splint  is  a  better  dressing  than  the  one  just 
described.  After  the  wound  has  been  dressed  with  gauze, 
plaster  is  at  once  applied  over  the  ends  of  brackets  (Fig. 
1 15).  The  above  methods  not  only  immobilize  the  fractured 
bones,  but  keep  the  parts  aseptic  and  afford  easy  access  to 
the  wound.  The  drainage-tubes  are  usually  removed,  if  sup- 
puration does  not  occur,  in  from  forty-eight  to  seventy-two 
hours.  The  wound  is  treated  as  any  other  wound.  In 
some  compound  fractures  there  is  difficulty  in  retaining  the 


TREATMENT  OF  FRACTURES.  4^5 

fra^^mcnts  in  apposition  (lower  end  of  femur,  upper  third  of 
feniur).  In  such  cases  the  ends  of  the  bone  should  be  resected 
and  the  bones  should  be  fastened  together  as  in  a  case  of 
united  fracture,  with  silver  wire,  aluminum  wire,  chromicized 
catgut,  or  kangaroo- tendon.  In  a  compound  fracture  of  the 
patella  after  free  incision  and  disinfection,  investigate  to  deter- 
mine the  gravitv  of  the  injur}-.  In  an  ordinary  case  in  which 
there  are  two  or  three  fragments,  open  the  joint,  irrigate  with 
saline  fluid,  drill  the  fragments,  and  fasten  them  with  silver 
wire.  Very  small  fragments  should  be  remo\-ed.  A  tube  is 
carried  into  the  joint,  the  wound  is  sutured  and  dressed,  and 
the  limb  is  immobilized.  In  cases  of  severe  compound  com- 
minuted  fracture  of  the  patella,  after  disinfection,  the  loose 


Fig.  115. -Bracketed  plaster-of-Paris  dressing. 

piece  should  be  removed  and  "  the  remaining  portions  made 
smooth  with  bone  forceps  and  the  sharp  spoon. "^  The 
wound  is  only  partially  sutured,  is  drained  and  dressed,  and 
the  Hmb  is  placed  on  a  splint.  A  compound  fracture  of  the 
skull  demands  trephining.  If  a  fracture  of  a  rib  is  com- 
pound internally,  resect  the  rib  ;  if  it  is  compound  externalh-, 
dress  antiseptically. 

Compound  fractures  may  be  followed  by  gangrene,  slough- 
ino-,  periostitis,  septicemia,  pyemia,  osteomyelitis,  necrosis, 
etc.'    The   treatment  of  these    conditions  is  by  well-known 

rules. 

Treatment  of  Delayed  Union  and  Ununited  Fracture.— 
When  delayed  union  exists,  seek  for  a  cause  and  remove  it, 
treating  constitutionally  if  required,  and  thoroughly  im- 
mobilizing the  parts  by  plaster.  Orthopedic  splints  may  be 
of  value.  Use  of  the  Hmb  while  splinted,  percussion  over  the 
fracture,  and  rubbing  the  fragments  together,  thus  in  each 
case  producing  irritation,  have  all  been  recommended. 
Blistering  the  skin  with  iodin  or  firing  it  has  been  employed. 
If  the  case  be  very  long  delayed,  forcibly  separate  the  frag- 

1  Lilienthal's  Imperative  Surgery. 


426  DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

ments  and  put  up  in  plaster  as  a  fresh  break.  If  these  means 
fail,  irritate  by  subcutaneous  drilling  or  scraping,  or,  better, 
by  laying  open  the  parts  and  then  drilling  and  scraping  at 
many  places.  Buechner  advocates  the  induction  of  hyper- 
emia by  a  constricting  band,  just  as  Bier  induces  congestive 
hyperemia  in  treating  tubercular  areas.  At  first  the  con- 
striction is  permitted  to  remain  but  a  short  time,  but  the 
period  is  lengthened  every  day,  until  in  a  {q.\\  days  it  remains 
almost  continuously  day  and  night.  He  claims  that  ten  days 
of  almost  continuous  application  cures  most  cases.  Helferich 
devised  this  method  in  1887.  Lannelongue  and  Menard  in- 
ject a  I  :  10  solution  of  zinc  chlorid  between  the  fragments. 
Leaving  acupuncture-needles  in  for  days  is  approved  by  some, 
and  electropuncture  is  advocated  by  others.  Cases  of  ununited 
fracture  must  be  treated  by  excision  of  the  bony  ends  and 
fibrous  tissue,  securing  the  fragments  together  by  periosteal 
sutures,  by  pins,  by  screws  and  plates,  by  ivory  pegs,  by  screws, 
by  silver  or  aluminum  bronze  wire,  by  kangaroo-tendon,  by 
Senn's  bone-ferrules,  or  by  chromicized  catgut.  Delorme 
makes  an  incision,  removes  bone-splinters  and  fibrous  tissue, 
smooths  off  one  end,  forces  this  into  the  bored-out  medul- 
lary canal  of  the  other  fragment,  and  sutures  the  periosteum. 
Gussenbauer's  clamp  will  often  give  a  good  result,  and  was 
used    for   years  by  Billroth.       Parkhill's    clamp   (Fig.    116) 


Fig.  116.— Parkhill's  clamp  for  ununited  fracture. 

secures  absolute  immobility  and  is  a  very  useful  instrument 
(see  Osteotomy  for  Ununited  Fracture,  p.  592). 

Treatvicnt  of  Vicious  Union. — If  angular  deformity  results 
from  faulty  union,  it  can  be  corrected  by  moulding  while  the 
callus  is  soft.  If  the  callus  has  become  hard,  the  bone  can 
be  refractured.  If  faulty  union  occurs  with  overriding,  an 
osteotomy  can  be  performed. 

Special  Fractures. — Nasal  Bones. — The  nasal  bones, 
because  of  their  situation,  are  often  broken.  The  commonest 
site  of  fracture  is  through  the  lower  third,  where  the  bones 
are  thin  and  lack  support.     The  fracture  may  be  compound 


SPECIAL    FRACTURES.  427 

externalh'  or  internally.  The  cause  is  direct  violence.  Dis- 
placement may  not  occur  at  all.  but  when  present  it  arises 
purely  from  force,  and  never  from  muscular  action,  no  mus- 
cle being  attached  to  these  bones.  If  the  force  is  from  the 
front,  the  nose  is  flattened ;  if  from  the  side,  it  is  deflected. 
Displacement  is  soon  masked  by  swelling.  Crepitus  can 
sometimes  be  elicited  by  grasping  the  upper  part  of  the  nose 
with  the  fingers  of  one  hand  and  moving  it  below  from  side 
to  side  with  the  fingers  of  the  other  hand.  Preternatural 
mobility  is  valueless  as  a  sign,  because  of  the  natural  mobilit}' 
of  the  cartilages.  Nose-breathing  is  difficult  because  of 
blocking  of  the  nostrils  by  blood-clot.  Diagnosis  may  be 
almost  impossible  when  deformit}'  is  absent. 

The  complications  that  may  be  noted  are  cerebral  concus- 
sion, brain-symptoms  from  implication  of  the  frontal  bone  or 
cribriform  plate  of  the  ethmoid,  and  extension  of  fracture  to 
the  superior  maxillar}^  or  lachr}'mal  bones.  Emphysema  of 
the  root  of  the  nose,  the  eyelids,  and  the  cheeks,  is  common, 
and  means  either  a  rent  in  the  mucous  membrane  of  Schneider 
or  a  crack  in  the  frontal  sinus.  There  ma}' be  much  discolor- 
ation because  of  subcutaneous  hemorrhage.  Epistaxis  is 
usual,  and  is  recognized  from  the  epistaxis  produced  by 
fracture  of  the  base  of  the  skull  b}'  the  facts  that  the  bleeding 
in  the  first  condition  is  profuse,  is,  as  a  rule,  soon  checked, 
and  is  not  followed  by  oozing  of  cerebrospinal  fluid  ;  whereas 
in  the  second  condition  it  is  profuse,  continued,  and  followed 
by  a  flow  of  cerebrospinal  fluid.  Fracture  of  the  bon}'  sep- 
tum occasionally  complicates  nasal  fractures,  and  deviation 
of  the  cartilaginous  septum  often  takes  place.  The  prognosis 
is  usually  good. 

Treatuioit. — \\'hen  there  is  no  displacement,  or  when  a 
displacement  does  not  tend  to  be  reproduced  after  reduction, 
employ  no  retentive  apparatus  of  any  kind.  Order  the 
patient  not  to  blow  his  nose  for  ten  days  and  syringe  it 
daily  with  a  solution  of  bicarbonate  of  sodium.  If  de- 
formity be  noted,  correct  it  at  once,  as  the  bones  soon  unite 
in  deformit\^  If  the  attempts  at  reduction  are  ver}-  painful, 
or  if  the  subject  be  a  child,  a  woman,  or  a  nervous  man,  give 
ether  or  spray  the  interior  of  the  nose  with  a  4  per  cent,  solu- 
tion of  cocain.  Reduction  is  effected  hy  a  grooved  director 
or  steel  knitting-needle,  wrapped  in  iodoform  gauze  and 
passed  into  the  nostril ;  the  fragments  are  lifted  with  this 
instrument,  and  the  fingers  externally  mould  them  into  place. 
A  rubber  dilator  can  be  used  in  reduction.  This  is  pushed 
into  the  nose  and  inflated  by  air  or  water.      If  hemorrhage 


428   DISEASES  AND   INJURIES   OE  BONES  AND  JOINTS. 


Fig.  117. — Mason's  pin. 


is  moderate,  check  it  with  cold  ;  if  severe,  by  plugging.  If 
flattening  tends  to  recur,  pass  a  Mason  pin  (Fig.  117)  ju.st 
beneath  the  fragments,  through  the  line  of  fracture  and  out 

the  opposite  side.  Steady  the 
fragments  by  a  piece  of  rubber 
externally  caught  on  each  end 
of  the  pin,  or  with  figure-of-8 
turns  around  the  ends  with  silk. 
Leave  the  pin  in  place  for  five 
days.  The  instrument  of  Ma- 
son is  a  sharp,  strong,  nickel- 
plated  pin,  with  a  triangular  point. 
If  a  lateral  deformity  tends  to 
recur,  hold  a  compress  over  the 
fracture  or  fix  a  moulded-rubber 
splint  over  the  nose  by  a  piece 
of  rubber  plaster  one  and  a  half 
inches  broad  and  long  enough 
to  reach  well  across  the  face,  and  use  compression  for 
ten  days.  In  neither  of  the  above  cases  is  the  nose  to 
be  blown,  and  in  both  cases  it  is  to  be  syringed  daily. 
In  fractures  rendered  compound 
membrane  irrigate  with  normal 
acid  solution,  holding  the  head  so 
run  into  the  mouth ;  plug  with  iodoform  gauze  around  a 
small  rubber  catheter,  which  instrument  permits  nose-breath- 
ing ;  carefully  remove  the  gauze  daily  and  syringe.  In  fract- 
ures compound  externally  cleanse  antiseptically  externally, 

and  dress  with  a  film  of  cotton 
soaked  in  iodoform  collodion  or 
compound  tincture  of  benzoin, 
or  apply  sterile  gauze.  Fractures 
of  the  bony  septum,  if  showing 
a  tendency  to  reproduction  of 
deformity,  require  packing  as 
above  explained,  or  the  use  of  a  special  splint  within  the 
nostrils  (Fig.  118).  Fractures  of  the  nasal  cartilages  are  to 
be  pinned  in  place.  Fractures  of  the  nose  are  entirely  united 
in  from  ten  to  twelve  days. 

Fractures  of  the  Lachrymal  Bone. — The  lachrymal  bone 
may  be  broken  when  the  nasal  bones,  a  superio  maxillary 
bone,  or  the  lateral  plate  of  the  ethmoid  are  fractured. 

Treatment. — Treat  the  chief  injury,  which  is  the  fracture 
of  the  other  bone.  Maintain  the  patency  of  the  lachrymal 
duct  by  passing  frequently  a  clean  probe. 


by  tears  in  the  mucous 
salt  solution  or  boracic- 
that  the  solution  will  not 


Fig.  118. — Jones's  nasal  splint. 


SPECIAL    FRACTURES.  429 

Fractui'es  of  the  Superior  Maxillary  Bone. — Although 
a  fragile  bone,  the  superior  maxillary  is  rarely  broken 
except   through    the   alveolar    border.     It    may   be    broken 

by  transmitted  force  from  blows  on  the  chin,  or  on  the  head 
when  the  chin  is  fixed  ;  but  direct  \iolence  is  the  usual  cause, 
and  the  wall  of  the  antrum  ma\'  be  crushed  in.  Comminu- 
tion is  the  rule,  and  the  injury  is  often  compound.  These 
fractures  induce  great  swelling,  pain,  and  inabilit)-  to  chew. 
]\Iobilit}-  and  crepitus  may  be  detected.  Deformit\-  is  due  to 
the  breaking  force,  and  not  to  the  action  of  any  muscle. 
When  a  portion  of  the  alveolar  arch  is  fractured,  as  may 
occur  in  pulling  teeth,  the  fragment  is  depressed  backward, 
and  there  exist  irregularit}-  of  the  teeth  (some  of  which  may 
be  loosened)  and  inability  to  chew  food.  Fracture  of  the 
nasal  process  is  apt  to  injure  the  lachr}'mal  duct.  When  the 
antrum  is  broken  in  there  are  great  sinking  over  the  fracture, 
depression  of  the  malar  bone,  and  emphysema.  Transverse 
fracture  of  the  upper  part  of  the  body  of  the  bone  may  cause 
no  deformity.  The  force  sufficient  to  break  the  superior 
maxillary  bone  is  so  great  that  fractures  of  other  bones 
almost  certainly  occur,  and  concussion  of  the  brain  not  infre- 
quently exists.  Injur}-  of  the  infraorbital  nerve  is  not  unusual, 
causing  pain,  numbness,  or  an  area  of  anesthesia  in\-oh-ing 
one-half  of  the  upper  lip,  the  ala  of  the  nose,  and  a  triangle 
whose  base  is  one-half  the  upper  lip  and  whose  apex  is  the 
infraorbital  foramen.  There  is  also  loss  of  sensation  in  the 
gums  and  upper  teeth  of  the  injured  side.  Fractures  of  the 
superior  maxillaiy  bone  occasionally  induce  fierce  hemor- 
rhage from  branches  of  the  internal  maxillar}'  artery ;  and  if 
this  occurs,  watch  out  for  secondar\-  hemorrhage  (these  ves- 
sels being  in  firm  canals). 

Treatment.— If  the  fracture  does  not  implicate  the  alveolus, 
or  if  no  deformit}-  exists,  apply  no  apparatus,  but  feed  the 
patient  on  liquid  food  for  four  weeks.  Reduce  deformit}',  if 
it  exists,  by  inserting  a  finger  in  the  mouth.  If  the  antrum 
is  broken  in,  put  the  thumb  in  the  mouth  and  push  the  malar 
bone  up  and  back.  In  certain  cases  of  deformit}'  make  an 
incision  at  the  anterior  border  of  the  masseter  muscle,  insert 
a  tenaculum  or  aneur}'sm-needle.  and  pull  the  bone  into  place 
( Hamilton ).  If  the  malar  bone  or  malar  process  is  driven 
into  the  antrum.  Weir  tells  us  to  incise  the  mucous  mem- 
brane above  and  external  to  the  canine  tooth  of  the  upper 
jaw,  break  into  the  antrum  with  a  bone-gouge,  insert  a  steel 
sound,  lift  out  the  malar  bone,  and  pack  the  antrum  with 
CTauze.     Loose  teeth  are  not  to  be  removed  ;  they  are  pushed 


430   DISEASES  AND  INJURIES   OF  BONES  AND  JOINTS. 

back  into  place  and  held  by  wiring  them  to  their  firmer 
neighbors.  Hemorrhage  is  arrested  by  cold  and  pressure. 
If  hemorrhage  is  dangerously  profuse  or  prolonged,  tie  the 
external  carotid. 

If  the  line  of  the  teeth,  notwithstanding  the  wiring,  is  not 
regular,  mould  on  an  interdental  splint.  The  usual  splint  for 
the  upper  jaw  is  the  lower  jaw  held  firmly  against  it  by  the 
Gibson,  the  Barton,  or  the  four-tailed  bandage.  Every  second 
day  remove  the  bandage  and  wash  the  face  with  ethereal 
soap.  The  patient,  who  is  ordered  not  to  talk,  is  to  live  on 
liquid  food  administered  by  pouring  it  into  the  mouth  back 
of  the  last  molar  tooth  by  means  of  a  tube  or  a  feeding-cup. 
Never  pull  a  tooth  to  get  a  space ;  but  if  a  tooth  is  lost,  utilize 
its  space  for  this  purpose.  After  every  meal  w^ash  out  the 
mouth  with  peroxid  of  hydrogen,  followed  by  chlorate-of- 
potassium,  boracic-acid,  or  normal  salt  solution,  and  thus 
prevent  foulness  and  the  digestive  disorders  it  may  induce. 
Leave  off  the  dressings  in  five  weeks,  and  let  the  patient 
gradually  return  to  ordinary  diet. 

In  fractures  corripound  externally  do  not  remove  frag- 
ments, antisepticize,  arrest  bleeding  as  far  as  possible  by 
ligature,  by  pressure,  or  by  plugging,  wire  the  fragments  if 
feasible,  dress  with  gauze,  and  wash  the  mouth  with  great 
frequency.  Fractures  compound  internally  are  treated  as 
simple  fractures,  except  that  the  mouth  is  washed  more 
frequently. 

The  malar  bone  is  rarely  broken  alone.  Hamilton  says 
no  uncomplicated  case  is  on  record.  The  malar  is  a  strong 
bone  resting  on  a  fragile  support,  and  hence  it  may  become 
a  wedge  to  break  other  bones  and  yet  itself  be  unfractured. 
The  catise  of  fracture  is  violent  direct  force.  A  fracture  of 
the  orbital  surface  of  this  bone  causes  subconjunctival  hemor- 
rhage like  that  encountered  in  fracture  at  the  base  of  the 
skull.  Protrusion  of  the  eye  may  result  either  from  hemor- 
rhage or  from  crushing  in  of  the  malar  bone.  Chewing  is 
apt  to  cause  pain. 

Treatment. — If  no  deformity  exists,  there  is  practically 
nothing  to  be  done.  If  deformity  exists,  tiy  to  correct  it  as 
in  fractures  of  the  superior  maxillary  bone.  As  these  cases 
are  almost  invariably  complicated  by  fracture  of  the  upper 
jaw,  they  are  treated  in  the  same  manner  as  the  latter 
injury.     The  union  is  complete  in  three  weeks. 

Fractures  of  the  zygomatic  arch  are  very  rare.  The 
causes  are  ( i)  direct  violence  ;  (2)  indirect  force  (from  depression 
of  the  malar) ;  and  (3)  forcing   of  foreign  bodies  through  the 


SPECIAL    FRACTURES.  43! 

mouth.  Direct  \-iolence  is  the  usual  cause.  Direct  violence 
causes  inward  displacement,  and  indirect  force  may  cause 
outward  displacement.  The  usual  seat  of  fracture  is  at  the 
smallest  portion  of  the  process — that  is,  on  the  temporal  side 
of  the  temporomalar  suture  (Matas).  The  symptoms  are 
pain,  ecchymosis,  swelling,  displacement,  and  difficulty  in 
moving  the  jaw  (because  of  injury  to  the  masseter  muscle). 

Treatment. — In  simple  fracture  give  ether  and  try  to  push 
the  arch  in  place.  Many  surgeons  do  not  make  an  incision, 
as  depression  will  do  no  harm  and  the  functions  of  the  jaw 
will  be  restored.  Simply  dress  with  a  compress,  adhesive 
strips,  and  the  crossed  bandage  of  the  angle  of  the  jaw.  Union 
will  take  place  in  three  weeks.  Matas  ^  advises  operation. 
An  anesthetic  is  administered,  and  the  parts  are  asepticized. 
A  long  semicircular  Hagedorn  needle  is  threaded  with  silk, 
is  entered  one  inch  above  the  middle  of  the  displaced  frag- 
ment, is  passed  well  into  the  temporal  fossa,  and  is  made  to 
emerge  half  an  inch  below  the  arch.  The  silk  is  used  to 
pull  a  silver  wire  through  around  the  fracture,  and  this  wire 
is  employed  to  pull  the  bone  into  position.  A  firm  pad  is 
applied  externally  and  the  wire  is  twisted  over  the  pad. 
Antiseptic  dressings  are  applied,  and  on  the  ninth  or  tenth 
day  the  wire,  splint,  and  dressings  are  removed  permanently. 
I  have  employed  this  plan  in  one  case  with  perfect  satisfaction. 

Fractures  of  the  inferior  maxillary  bone  may,  and  most 
usually  do,  affect  the  body,  although  they  occasionally  occur 
in  the  rami.  Any  part  of  the  body  may  be  fractured,  the  most 
usual  seat  being  near  the  canine  tooth  or  a  little  external  to 
the  symphysis  (Pick).  A  portion  of  alveolus  may  be  broken 
off.  In  fractures  of  the  ramus  either  the  angle,  the  condyloid 
neck,  or  the  coronoid  process  may  be  broken.  In  fractures 
of  the  body  the  posterior  fragment  generally  overrides  the 
anterior.  Fractures  of  the  lower  jaw  are  often  multiple 
and  are  almost  always  compound,  because  the  oral  mucous 
membrane  and  alveolar  periosteum  are  torn.  The  cause  is 
usually  direct  violence.  Indirect  violence  (lateral  pressure) 
may  fracture  the  body  anteriorly.  Fractures  near  the  angle 
are  always  due  to  direct  \dolence.  Indirect  violence  may 
fracture  the  condyle  (falls  on  the  chin),  and  so  may  direct 
violence.  Fractures  of  the  coronoid  process  are  ver>^  rare, 
and  they  arise  from  great  direct  violence  (usually  a  gunshot- 
wound  or  some  other  penetrating  force). 

Symptoms. — In  fracture  of  the  body  preternatural  mobility 
and  crepitus   generally  exist.     There  is  bleeding  because  of 

1  New  Orleans  Med.  and  Surg.  Jour.,  September,  1896. 


432   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

laceration  of  the  gums;  saliva  dribbles  constantly ;  the  patient 
supports  the  jaw  with  the  hand ;  great  pain  exists  (possibly 
from  injury  of  the  nerve) ;  and  deformity  is  present,  shown  by 
inequality  of  the  teeth  if  the  fracture  is  anterior  to  the  mas- 
seter,  the  anterior  fragment  eoino;  downward  and  backward 
and  the  posterior  fragment  going  upward  and  forward.  The 
downward  displacement  is  due  to  muscular  action  (action  of 
the  digastric,  geniohyoid,  and  geniohyoglossus).  The  back- 
ward displacement  is  due  to  the  violence.  The  temporal  mus- 
cle draws  the  posterior  fragment  upward  and  to  the  front.  In 
fracture  of  the  neck  of  the  condyle  the  jaw  is  drawn  toward 
the  injured  side,  and  the  condyle  is  pulled  inward  and  forward 
by  the  action  of  the  external  pterygoid  muscle.  In  fracture 
of  the  coronoid  process  the  temporal  muscle  pulls  the  small 
fragment  upward. 

Couiplications. — The  complications  are — digestive  disorders 
and  diarrhea  from  swallowing  foul  discharges ;  loosening  of 

the  teeth ;  lodgement  of  loos- 
ened teeth  between  the  frag- 
ments; bleeding(usually  only 
oozing  from  the  gums,  but 
there  may  be  hemorrhage 
from  the  inferior  dental 
artery);  and  suppuration. 
Necrosis  may  follow  these 
fractures. 

Treatment.  —  Remove  a 
tooth  if  it  lies  between  the 
fragments,  but  replace  it  in 
its  socket  after  reducing  the 
fracture.  Correct  deformity. 
Push  loose  teeth  into  place 
and  put  back  detached 
ones.    Wash  the  mouth  with 

Fig.  iig. — Hamilton's  bandage.  ,        ■  ,  ,  ,  .,  ,    ^ 

hot  water  to  clean  it  and  to 
check  bleeding.  If  bleeding  is  very  severe,  compress  the 
carotid  artery  for  a  time.  The  fracture  can  be  dressed  with 
a  pad  of  lint  over  the  chin  and  Hamilton's  four-tailed  band- 
age (Fig.  119).  A  common  plan  is  to  take  a  splint  of  paste- 
board, felt,  or  gutta-percha  ;  pad  it  lightly  with  cotton,  mould 
it  to  the  part,  and  hold  it  in  place  with  a  Barton  or  a  Gibson 
bandage.  If  apposition  of  the  fragments  cannot  be  main- 
tained by  the  above  methods,  fasten  the  teeth  together 
with  wire,  wire  the  fragments  together,  or  have  a  den- 
tist apply  an  interdental  splint  (Figs.  120,   121).     Fracture 


SPECIAL    FRACTURES. 


433 


of  the  lower  jaw  can  often  be  most  satisfactorily  treated  by  the 
Angle's  bands.  These  bands  are  of  great  value  in  compli- 
cated cases,  in  which  two  or  more  fractures  exist.  Each 
band  consists  of  thin  metal  and  a  screw  and  a  nut  to  fit  the 
screw.  The  band  is  adjusted  around  a  firm  tooth  and  the  nut 
is  applied  so  as  to  hold  the  band  tight!}-.     Several  bands  are 


Fig.  I20. — ^  ulcanite  splint  with  boxes  vulcanized  lii  each  side.  If  the  jaw  is  fractured  in 
the  region  of  the  molars,  considerable  pressure  is  required  to  get  the  parts  in  position  :  there- 
fore it  is  best  to  vulcanize  on  to  the  sides  of  the  vulcanite  splint  boxes  into  which  wire  arms 
can  be  inserted  (Pilcher). 

placed  upon  teeth  in  both  jaws.  Silver  wire  or  silk  is  thrown 
around  the  pins  of  the  bands  so  as  to  catch,  and  the  jaws  are 
thus  held  firmly  together.  I  have  had  these  bands  applied 
for  me  in  fracture  of  the  jaw  with  excellent  result  by  Dr.  C. 
P.  Chopein.     The    patient    is    to   be  fed  on   liquid  food  (see 


Fig.  121. — Interdental  splints. 

Fracture  of  the  Upper  Jaw,  p.  430),  the  mouth  is  to  be 
washed  frequently  with  peroxid  of  hydrogen,  followed  by 
boric-acid  solution  or  normal  salt  solution,  and  the  dressings 
are  to  be  changed  ever}^  second  day.  The  union  should 
be  complete  in  five  weeks.  Though  these  fractures  are 
usually  compound,  they  do  not  endanger  life. 

Fractures  of  the  Hyoid  Bone. — These  fractures  are  rare 

23 


434   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

injuries,  and  are  caused  by  hanging,  by  the  throat  being 
grasped  by  an  antagonist,  and  by  falls  in  which  the  neck 
strikes  some  obstacle.  If  the  bone  breaks  by  throttling,  it 
is  its  body  which  fractures  (indirect  force).  Fractures  by 
muscular  action  are  most  unusual. 

Symptoms. — The  symptoms  are — a  sensation  of  something 
breaking;  bleeding  from  the  mouth  if  the  mucous  membrane 
be  lacerated;  pain,  which  is  worse  on  opening  the  jaws  or 
on  moving  the  head  or  tongue ;  difficulty  in  swallowing  ; 
muffled,  hoarse,  or  absent  voice ;  swelling,  and  frequently 
ecchymosis,  of  the  neck.  There  are  observed  occasionally, 
though  rarely,  harsh  cough  and  dyspnea,  irregularity  of 
bony  contour,  and  crepitus.  Always  look  into  the  mouth 
and  see  if  there  can  be  detected  ecchymosis  or  laceration  of 
the  mucous  membrane  or  projection  of  a  bony  fragment. 
The  displacement  is  due  to  the  middle  constrictor  of  the 
pharynx  contracting.  A  fracture  of  the  hyoid  bone  may 
destroy  life. 

Treatment. — For  dyspnea,  be  ready  to  perform  intubation 
or  tracheotomy  at  a  moment's  notice.  Edema  of  the  glottis 
is  a  great  danger.  Try  to  restore  the  fragments  with  one 
hand  externally  and  with  a  finger  in  the  mouth.  Put  the 
patient  to  bed  and  have  him  lie  back  upon  a  firm  rest  so  that 
his  shoulders  are  elevated.  His  head  is  to  be  placed  between 
extension  and  flexion,  a  pasteboard  splint  or  collar  is  moulded 
on  the  neck,  and  a  bandage  is  applied  around  the  forehead, 
neck,  and  shoulders  to  keep  the  head  immobile.  The  patient 
must  not  utter  a  word  for  a  week ;  he  must  at  first  be  fed  by 
enemata,  and  then  for  some  time  on  liquid  diet,  which  is  given 
through  a  tube  early  in  the  case.  Endeavor  to  control  the 
cough  by  opiates.  A  fractured  hyoid  bone  requires  about 
four  weeks  to  unite. 

Fracture  of  laryngeal  cartilages  is  caused  by  direct 
violence,  as  throttling,  blows,  or  kicks.  It  is  rare  in  young 
persons,  and  is  commonest  when  the  cartilages  have  begun 
to  ossify.  It  is  a  very  grave  injury,  death  arising  from 
obstruction  to  the  entrance  of  air. 

Symptoms. — The  symptoms,  which  are  severe,  are  pain, 
aggravated  by  attempts  at  swallowing  or  speaking ;  swelling, 
ecchymosis  it  may  be,  and  emphysema  of  the  neck  ;  cough  ; 
aphonia;  intense  dyspnea;  and  bloody  expectoration  if  the 
mucous  membrane  is  ruptured.  There  can  be  detected  in- 
equality of  outline  (flattening  or  projection)  and  perhaps 
moist  crepitus.  The  usual  seat  of  the  injury  is  the  thyroid 
cartilage. 


SPECIAL   FRACTURES.  435 

Treatment. — Cases  without  dyspnea  require  quiet,  avoid- 
ance of  all  talking,  feeding  with  a  stomach-tube,  the  applica- 
tion of  compresses  and  adhesive  strips  over  the  fracture,  and 
the  use  of  remedies  to  quiet  cough.  The  surgeon  must  be 
ready  to  operate  at  any  moment.  In  most  cases  dyspnea 
exists,  due  to  projection  of  the  fragments  or  submucous  ex- 
travasation. When  there  is  dyspnea,  emphysema,  or  spitting 
of  blood,  at  once  practise  intubation,  or,  if  unable  to  do  this, 
open  the  lar}mx  or  trachea  below  the  seat  of  fracture.  If 
laryngotomy  or  tracheotomy  is  performed,  try  to  restore  to 
proper  position  displaced  fragments.  If  the  fragments  will 
not  remain  reduced,  introduce  a  Trendelenburg  cannula  or 
a  tracheotomy-tube,  around  which  gauze  is  packed.  Take 
out  the  packing  in  four  days,  and  remove  the  tube  as  soon  as 
the  patient  breathes  well,  when  the  opening  may  be  allowed 
to  close.  In  these  fractures  feed  with  a  stomach-tube  and 
keep  the  patient  absolutely  quiet.  Union  takes  place  in  four 
weeks. 

Fractures  of  the  Ribs. — The  ribs,  owing  to  their  shape, 
elasticity,  and  mode  of  attachment,  readily  bend  and  as  read- 
ily recover  their  shape,  and  thus  withstand  considerable  force 
without  breaking.  Notwithstanding  these  facts,  the  situation 
of  the  ribs  so  exposes  them  that  in  i6  per  cent,  of  all  cases 
of  fractures  noted  by  Gurlt  these  bones  were  involved.  In 
children  this  injury  is  rare  and  isrnost  usually  incomplete.;_Lt ,. 
is  common  in  adults  andthe  aged,  and  in  them  is  generally 
complete.  It  is  more  frequent  among  men  than  among 
women.  The  ribs  commonly  broken  are  from  the  fifth  to 
the  ninth,  the  seventh  being  the  one  that  usually  suffers. 
Fracture  of  the  first  rib  alone  is  an  excessively  rare  accident. 
The  eleventh  and  twelfth  ribs  are  seldom  broken.  A^nb- 
ma\-  be  broken  in  several  places,  and  several  ribs  are  often 
broken  at  the  same  time.  Fracture  of  a  single  rib  is  not 
nearly  so  common  as  fracture  of  several  ribs.     These  fract- 

"jlcea  may  be  compound  either  through  the  skin  or  through 
the  pleura,  a  damaged  lung  permitting  pneumothorax.  Com- 
pound fractures  are  very  rare,  however,  except  from  bullet-  _ 
:wounds. 

Vauses.—,Dire£tSQrc^,  as  buffer  accidents,  kicks,  blows  with 
heavy  instruments,  or  being  jumped  on  while  recumbent, 
may  produce  these  injuries.  A  fracture  froni  direct  violence 
occurs  atjthe_pqint  struck,  and  the  ends,  projecting  inward, 
rriay^amage    a   viscus..     Indirect   force,  as    great,  pressure 

^oTBTmvs  which  exaggerate  the  natural  bony  curves^Jends  to 
produce  fractures  near  the  rpiddle  of  the  ribs  or  in  front  of 


436   DISEASES  AND   IXJUKIES    OF  BONES  AND  JOINTS. 

their  angles  and  to  force  the  ends  outward.  A  number  of 
ribs  are  apt  to  be  broken.  Muscular  action,  as  in  coughing 
or  parturition,  occasionally,  but  very  rarely,  is  a  cause. 

Syviptorns. — In  connection  with  the  history  of  the  acci- 
dent the  symptoms  are — acute  localized  pain  (a  stitch)  on 
breathings  increased  by  pressure  over  the  injury,  pressure 
backward  over  the  sternum,  cough,  and  forcible  inspiration 
or  exfxirati.Qnj  respiration  is  largely  diaphragmatic,  the  patient 
endeavoring  to_ immobilize  the  injured  side;  cough  is  frequent 
and  is  suppressed  because  of  pain.  Crepitus  is  often  but  not 
invariably  founds  It  is  sought,  first,  by  resting  the  palm 
over  the  seat  of  pain  while  "tlie^pafiefft  Take's  long  breaths  ; 
second^  by  placing  a  thumb  iDefo re  and  one  behind  the  seat 
of  pain  and  making  alternate  pressure;  and  third,  by  auscul- 
tation. It  should  be  remembered  that  incomplete  fractures 
are  the  rule  in  children ;  hence  in  them  do  not  expect  crepi- 
tus. Deformity  is  usually  trivial  unless  several  ribs  are 
broken,  because  shortening  cannot  occur  and  the  intercostal 
attachments  prevent  vertical  displacement.  Preternatural 
mobility  may  occasionally  be  elicited,  when  the  region  is  not 
deeply  covered  with  muscles,  by  pressing  on  one  side  of  the 
supposed  break  and  observing  that  a  part  of,  and  not  the 
entire,  rib  moves.  If  ^ir  gathers  in  the  subcutaneous  tissue 
and  there  is  no  w^ound  of  the  surface,  it  is  proof  of  rib  fract- 
ure with  lung-damage.  In  such  a  case  the  lung  has  been  pene- 
trated by  a  fragment,  and  air  has  been  forced  out  into  the  tissues. 
This  condition  is  recognized  by  great  and  growing  swelling, 
which  crackles  when  touched.  Such  a  collection  of  air  is 
known  as  cellular  emphysema.  Bloody  expectoration  sug- 
gests lung  injury;  bloody  expectoration  and  cellular  emphy- 
sema,  without  an  external  wound,  prove  injury  of  the  lung. 
A  simple,  uncomplicated  case  in  a  young  person  gives  a  good 
prognosis. 

The  complications  are — additional  injury,  making  the  fract- 
ure externally  or  internally  compound ;  laceration  pf_the 
pleura,  pericardium,  heart,  lung,  diaphragm,  liver,  spleen,  ©r 
colon  ;  rupture  of  an  intercostal  artery ;  hemothorax  ;  cellu- 
lar emphysema  ;  pulmonary  emphysema  ;  pneumothorax  and 
pyothorax  ;  traumatic  pleurisy  ;  pneumonia ;  bronchitis  ;  con- 
gestion or  edema  of  the  lungs. 

Treatment. — In  an  uncomplicated  case  the  patient  is  not 
kept  in  bed,  as  breathing  is  easier  when  erect  than  when 
recumbent.  Angular  displacement  outward  is  corrected  by 
direct  pressure.  Displacement  inward  is  soon  corrected,  as 
a  rule,  by  the  expansion  of  ordinary  respiratory  action  ;  but 


SPECIAL    FRACTURES.  437 

if  it  is  not  thus  corrected,  etherize,  the  deep  breathing  of  the 
anesthetic  state  ahnost  always  succeeding.  Ifcther  fails  and 
dangerous  symptoms  come  on,  incise  under  strict  antiseptic 
precautions,  elevate,  and  drain,  or  sometimes  resect  the  rib. 

After  correcting  an)'  existing  deformity  immobilize  the 
injured  side.  Direct  the  patjent  to  raise  his  arms  above  his 
head^  to  empty.  hrs""^h"est-air  by  a  forced  expiration,  and  to 
keep_ii_enipt}'  until  a  piece  of  rubber  plaster  (two  inches 
wide)  is  forcibly  applied  seven  or  eight  inches  below  the  fract- 
ure and  from  the  spine  to  the  sternum.  The  patient  is  now 
aIIowed~tcr^tai<e  a  breath  and  is  directed  to  empty  the  chest 
again,  another  piece  of  plaster  being  applied,  covering  the 
upper  two-thirds  of  the  width  of  the  first  strip.  This  proc- 
ess^ is  continued  until  the  side  is  strapped  well  above  and 
well  below  the  fracture  (PI.  6,  Fig.  13).  Over  the  plaster 
liglit  turns  of  a  spiral  bandage  of  muslin  are  carried,  or  a 
figure-of-8  bandage  of  the  chest  is  applied,  the  turns  crossing 
over  the  seat  of  injury.  .-Ibput  once  a  week  the  plaster  is 
removed  and  fresh  pieces  applied  after  rubbing  the  chest 
wittrsbap  liniment,  drying,  and  anointing  excoriations  with 
an  ointment  of_oxid  of  zinc.  The  dressing  is  worn  for  three 
orlour^weeks.  The  patient  avoids  cold,  damp,  and  draughts. 
The  diet  must  be  nutritious  but  non-stimulating,  and  any 
cough  should  be  treated  by  opiates  and  expectorants.  A 
person  with  this  injury  who  has  reached  the  age  of  sixty 
must  take  stimulant  expectorants  (ammonii  carb.,  gr.  x,  in 
infus.  senegae,  5ss,  t.  i.  d.)  or  employ  a  steam-tent  several  times 
a  da^^  The  old  method  of  treatment,  in  which  the  chest  was 
included  in  a  forcibly  applied  broad  rib-roller,  is  not  to  be 
used  except  as  a  temporary  expedient ;  it  compresses  the 
entire  chest,  causes  pain  and  dyspnea,  and  tends  to  loosen 
and  slip. 

Fracture  of  the  ribs  complicated  with  visceral  injury  is 
highly  dangerous,  and  requires  confinement  to  bed.  The 
treatment  is  that  of  the  visceral  injury.  If  there  be  bloody 
expectoration,  apply  adhesive  strips  as  above  indicated,  put 
the~patient  to  bed  reclining  on  a  bed-rest,  keep  him  quiet, 
subdue  the__circulation,  and  employ  opium,  diaphoretics,  and 
expectorants  (a  good  mixture  consists  of  squill,  ipecac,  am- 
monium acetate,  and  chloroform  ;  opium  is  given  separately). 
Inflammations  of  the  lung  or  the  pleura,  fortunateh',  are  apt 
to  be  localized,  and  are  treated  as  are  ordinar\'  inflammations 
of  these  parts.  If  signs  of  pulmonar\'  inj  un,"  are  severe  from  the 
start  or  become  worse  under  medical  treatment,  incise,  resect 
a  rib,  arrest  hemorrhage,  and  drain  the  pleura.     In  lacera-_ 


438   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

tion  of  an  intercostal  artery  incise  and  try  to  ligate ;  if  un- 
able to  ligate,  resect  a  rib  and  apply  a  ligature.  If  the  signs 
point  to  internal  bleeding,  resect  a  rib,  search  for  the  bleed- 
ing point,  and  ligate.  Emphysema  usually  soon  disappears  ; 
but  if  it  does  not,  make  many  small  incisions  in  the  cellular 
tissue,  dress  antiseptically,  and  employ  pressure.  WJien^lhere- 
arises  a  sudden  attack  of  dyspnea,  which  is  prone  to  happen 
in^Bese  cases,  and  in  which  the  face  becomes  blue,  the  heart 
labors,  and  suffocation  seems  imminent,  bleed  the  patient 
almost  to  syncope. 

Fractures  of  the  costal  cartilages  are  not  common, 
even  in  the  aged.  Such  fractures  occur  either  through  the 
cartilages  or  through  their  points  of  junction  with  the  ribs. 
These  injuries  generally  arise  from  direct  violence,  the  carti- 
lage of  the  eighth  rib,^eing  most  prone  to  suffer.  Indirect 
force  (such  as  a  blow  upon  the  shoulder)  is  occasionally  tlie 
cause,  but  when  it  is  the  cause  some  other  injuiy  besides  the 
fracture  of  the  cartilages  is  apt  to  be  noticed.  MuaoiUr 
action  is  a  possible  cause. 

Symptoms. — Displacement  is  often  absent ;  but  if  present,  it 
is  forward  or  backward  of  either  fragment,  and  is  due  chiefly 
to  the  force  of  the  injury,  but  partly,  it  may  be,  to  muscular 
action.  When  displacement  is  absent  crepitus  will  not  often 
be  found;  in  fact,  crepitus  is  usually  absent  in  these  injuries. 
Localized  pain,  swelling,  and  ecchymosis  are  noted.  Preter- 
natural mobility  may  or  may  not  be  detected.  Union  by 
bone  is  to  be  expected. 

Treatment. — If  .displacement  exists,  try  to  reduce  it.  If 
the  fragment  is  displaced  backward,  reduce  by  deep  inspira- 
tions ;  if  the  fragment  is  displaced  forward,  reduce  by  pulhng 
back  the  -shoulders.  In  this  attempt  failure  is  the  rule, 
and  the  surgeon  may  then  adopt  Malgaigne's  expedient 
of  applying  a  truss  over  the  projection  for  a  day  or  two. 
Dress  and  treat  the  case  as  if  a  rib  were  broken,  removing 
the  dressings  in  four  wrecks.        ^»*-'~l'" 

Fractures  of  the  Sternum. — The  sternum  may  be  broken, 
along  with  the  ribs  and  spine,  from  great  violence.  Fract- 
ures of  the  sternum  alone  are  infrequent,  because  the  bone 
rests  on  a  spring-bed  of  ribs.  Fractures  of  the  sternum  may 
be  simple  or  compound,  complete  or  incomplete,  single  or 
multiple.  The  most  usual  injury  is  a  simple  transverse  fract- 
ure at  or  near  the  gladiomanubrial  junction,  at  which  point 
dislocation  may  also  occur.  Both  fracture  and  separation 
of  the  ensiform  cartilage  are  very  rare.  The  sternum  may 
be  broken  along  with  the  ribs  or  clavicle. 


SPECIAL   FRACTURES.  439 


^^,,^,-,-_The  causes  of  fracture  of  the  sternum  are— 
direct  force,  as  by  a  fall  of  an  embankment  or  of  a  wall  by  a 
car-crush,  or  by  the  passing  of  a  cart-wheel  over  the  body ; 
indirect  force,  as  by  a  fall  upon  the  head  thus  driving  the 
chin  against  the  chest;  by  a  fall  upon  the  feet,  the  buttocks, 
or  the  shoulder;  by  forced  flexion  or  extension  of  the  body 
over  an  edge  or  angle  (as  may  occur  during  labor-pains). 

SvinMoms—lx^  fracture  of  the  sternum  displacement  is  not 
always  present,  but  when  it  does  occur  the  lower  fragment 
is  apt  to  pass  forward ;  displacement  may,  however,  be  trans- 
verse or  angular,  or  there  may  be  overriding.     The  posterior 
pei-iosteum,  which  rareh'  tears,  limits  displacement,  but  sorne 
deformlt^-  ^ran.  as  a  rule,  be  detected.     The  history  of  the 
nature  of  the  accident  has  a  valuable  beanng  upon  the  ques- 
tion of  diagnosis.     The  position  assumed  by  the  patient  is 
^vith  the  heSd  and  bod)'  bent  forward,  as  attempts  to  straighten 
Im  cause  much  suffering.     There  is  fixed  and  localized  pam, 
increased  bv  deep  respirator)^  action,  by  body-movements,  or 
bv  cough.'  Crepitus  is  sought  for  by  auscultation  and  by 
p  acing  the  hand  over  the  injuiy  and  directmg  the  patient  to 
make  quick  respirations.     Mobility  may  become  manliest  on 
external  pressure,  during  respiration,  or  while  atten.pt.  a  e 
beino-  made  to  bring  the  bod>-  erect.     Respiration  m  these 
case?  IS  usually  much  interfered  with.     It  is  not  important  to 
separate  diastasis  from  fracture. 

O;;//'//ar//.^;/.-.-0ther  fractures  generally  complicate  fract- 
ure of  the  sternum,  and  laceration   of  the  pleura  or  pen- 
caJdium  and  hemorrhage  into  the  antenor  mediastinum  may 
exist       Abscess  of  the  mediastmum  and  necrobis  of  the  ster 
^ummav  appear  as   late   consequences.      The  Prognosis  is 

^°t:;.:i:;n^hell;:S?-attending  ^acture  of  the  ste. 
num   s  to  be  corrected,  if  possible,  by  external  pressure^    If 
o  Sridi^.-  is  found,   effect  reduction  by  bending  the  body 
back  o'^?  a  firm  pillow  and  ordering  the  patient  to  respi  e 
deeplv     if  this  method  fails,  give  ether  and  then  bend  the 
bodv  backward      The   deformity,  after  reduction,  tends    to 
relr  but  the  bones   unite  well  even  in  deformit)^  and  no 
great-harm  results.    The  fragments  need  not  be  -t  do.n  on 
Sr  be  hooked  up  unless  there  be  internal  injur)      A[  ^r  re^^ 
ing  the  deformit)-.  cover  the  front  of  the  _<:h^f^;\f^^;^j^^;^^ 
strips  extending  laterally  from  one  axillar)Tine  to  the  othei  and 
co^-erinc.  a  regfon  from  above  the  fracture  down  to  the  ensi- 
forrcartilacxe     Place  over  this  covering  an  antenor  figure-of-8 
ba  "da"   of  ?he  chest.     In  some  cases,  where  deformity  recurs 


440   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

after  reduction,  a  circular  bandage  of  the  chest  is  applied  and 
the  shoulders  are  pulled  strongly  back  with  a  posterior  fig- 
ure-of-8  bandage.  The  plaster  is  to  be  reappHed  once  a 
week.  Some  surgeons  treat  these  cases  by  means  of  a 
large  compress  held  by  adhesive  plaster  and  a  broad  tight 
roller. 

The  patient  must  be  promptly  put  to  bed,  and  reposes  erect 
or  semi-erect  on  a  bed-rest.  This  position  favors  easy  respi- 
ration and  antagonizes  the  tendency  to  displacement.  The 
diet  should  be  light,  nutritious,  and  non-stimulating.  The 
patient  becomes  convalescent  in  four  weeks,  and  the  plaster 
should  be  permanently  removed  in  five  weeks.  When  the 
ensiform  cartilage  is  so  bent  in  as  to  cause  intense  pain  or  to 
injure  the  stomach,  it  should  be  exposed  by  incision  and 
resected.  Edema  of  the  skin  and  fever,  if  they  appear,  indi- 
cate pus,  in  which  case  an  incision  should  be  made  at  the 
edge  of  the  sternum  and  the  pus-cavity  should  be  irrigated 
and  drained. 

Fractures  of  the  Pelvis. — In  some  of  the  indicated  fract- 
ures serious  injury  of  the  pelvic  contents  is  apt  to  be  found. 

Fractures  of  the  False  Pelvis. — Fractures  of  this  region 
are  seldom  dangerous  unless  comminuted.  There  may  be 
fracture  of  the  iliac  crest  or  of  the  anterior  superior  spine,  or 
the  line  of  fracture  may  traverse  the  entire  length  of  the 
flanged-out  ilium,  or  the  bone  may  be  comminuted  with  the 
association  of  grave  visceral  damage.  The  anterior  superior 
and  posterior  superior  spines  may  be  broken  off 

Causes. — The  cause  of  fracture  of  the  false  pelvis  is  gener- 
ally violent  dh-ect  force,  as  the  passage  of  a  wagon-wheel, 
the  fall  of  a  wall,  the  kick  of  a  horse  or  mule,  or  the  force 
of  car-crushes.  Violent  contraction  of  the  rectus  muscle 
may  tear  off  the  anterior  inferior  spine  of  the  ilium. 

Symptoms. — In  fracture  of  the  false  pelvis  the  history  of 
violent  force  is  noted.  The  patient  leans  toward  the  injured 
side.  Pain  exists,  which  is  aggravated  by  movements  (par- 
ticularly by  bending  forward),  by  coughing,  or  by  straining 
to  empty  the  bowels  or  the  bladder.  Ecchymosis  and  swell- 
ing are  manifest.  Crepitus  and  preternatural  mobility  are 
detected  by  moving  the  iliac  crest.  Deformity  is  very  rarely 
present.  Cases  uncomplicated  by  visceral  injury  make  good 
recoveries. 

Complications. — The  fracture  may  be,  but  rarely  is,  com- 
pound, as  the  parts  are  well  protected  with  muscles.  The 
colon  may  be  injured  when  comminution  has  taken  place. 

Treatment. — In  treating  fracture  of  the  false  pelvis  put  the 


SPECIAL   FRACTURES.  44 1 

patient  on  a  fracture-bed,  raise  the  shoulders,  and  apply  a 
binder  about  the  pelvis,  or  encase  the  pelvis  with  broad  pieces 
of  rubber  plaster,  or  employ  the  belt  or  girdle.  Place  the 
knees  over  two  pillows  so  as  to  semiflex  the  legs  and  thighs, 
and  tie  the  knees  together.  To  restrain  thigh-movements  it 
may  be  necessary  to  encase  a  restless  patient  with  splints  or 
bind  him  to  sand-bags.  If  the  binder  displaces  the  fragments 
or  causes  pain,  abandon  it  and  trust  to  position.  The  dress- 
ings can  be  removed  in  six  weeks,  and  the  patient  is  allowed 
to  get  up  in  eight  weeks.  In  compound  fractures  of  the  false 
pelvis  asepticize,  drain  and  dress,  put  on  a  binder,  and  direct 
the  same  position  to  be  maintained  as  for  simple  fractures. 

Fractures  of  the  True  Pelvis. — The  most  usual  seat  of 
these  fractures  is  through  the  obturator  foramen,  the  ascend- 
ing ischial  and  horizontal  pubic  rami  being  broken.  A  fract- 
ure may  occur  near  the  symphysis  pubis,  the  symphysis 
may  be  separated,  a  break  may  run  near  to  or  into  the  sacro- 
iliac joint,  the  same  fracture  may  occur  on  each  side  of  the 
body  of  the  pubis,  and  there  may  be  multiple  fractures. 
Fractures  of  the  acetabulum  and  of  the  tuberosity  of  the 
ischium  may  occur.  Before  the  seventeenth  year  the  innomi- 
nate bone  may  be  broken  into  its  three  anatomical  segments. 
These  injuries  are  highly  dangerous  because  of  the  damage 
which  is  apt  to  be  inflicted  on  the  pelvic  contents.  There 
may  be  rupture  of  the  bladder  or  membranous  urethra  and 
injury  of  the  vagina,  the  rectum,  the  uterus,  or  the  small 
gut.  The  cimse  of  pelvic  fracture  is  violent  force,  direct  or 
indirect.  Front  force  tends  to  produce  direct,  and  side  force 
indirect  fracture.  The  acetabulum  may  be  broken  by  falls 
upon  the  feet. 

Symptoms. — In  pelvic  fracture  there  is  a  history  of  violent 
force.  There  are  great  shock,  ecchymosis  which  is  possibly 
linear,  swelling,  and  intense  pain  increased  by  attempts  at 
motion,  coughing,  and  straining.  There  is  also  inability  to 
sit  or  to  stand.  Mobility  becomes  obvious  on  grasping  an 
ilium  in  each  hand  and  moving  the  hands.  Crepitus  may  be 
noticed  by  this  maneuver  or  by  moving  an  ilium  with  one 
hand,  a  finger  of  the  other  hand  being  inserted  in  the  rectum 
or  vagina.  In  making  movements  for  diagnostic  purposes 
be  very  gentle,  as  rough  manipulation  may  cause  injury  by 
sharp  fragments.  There  may  be  doubt  as  to  whether 
crepitus  is  to  be  referred  to  pelvic  fracture  or  to  fracture 
of  the  neck  of  the  femur ;  in  this  case  follow  the  rule  of 
John  Wood:  "The  surgeon  grasps  the  femur  with  one 
hand   and  places  the  other  firmly  upon    the  anterior  supe- 


442   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

rior  iliac  spine  or  crest  or  upon  the  pubes  ;  then,  on  moving 
the  femur  and  abducting  it  freely,  if  a  crepitus  be  detected, 
it  will  be  felt  the  more  distinctly  by  that  hand  which  rests 
on  or  grasps  the  fractured  bone." 

Injury  of  the  bladder  or  urethra  is  made  manifest  by  reten- 
tion of  urine,  extravasation  of  urine,  hematuria,  etc.  In 
some  cases  the  urine  is  extravasated  into  the  prevesical 
space.  Bleeding  from  the  vagina  or  the  rectum  points  to  a 
laceration  of  the  part  by  a  fragment.  The  vagina  may  be 
badly  lacerated  and  the  bowels  may  emerge  from  the  lacera- 
tion (Morris  Richardson's  case).  Intestinal  injury  is  apt  to 
induce  septic  peritonitis.  Fracture  of  the  brim  of  the  acetab- 
ulum permits  dorsal  dislocation  of  the  femur  to  occur,  which 
dislocation  will  not  remain  reduced.  Fracture  of  the  brim  of 
the  acetabulum  causes  shortening,  which  at  once  recurs 
when  extension  is  abandoned — inversion  and  adduction, 
although  the  power  of  eversion  and  abduction  is  preserved 
(Stokes).  There  is  crepitus,  and  the  head  of  the  bone  goes 
with  the  fragment  upward  and  backward  (Stokes).  If  the 
head  of  the  femur  be  driven  through  the  acetabulum  into 
the  pelvis,  the  injury  is  very  grave;  there  are  then  found 
shortening,  adduction,  and  semiflexion  of  the  thigh,  absence 
of  the  prominence  of  the  great  trochanter,  and  more  capacity 
for  movement  than  is  noted  in  dislocation.  Fracture  of  the 
ischium  rarely  occurs  alone. 

Treatment. — Examine  carefully  to  see  if  the  bowel,  the 
bladder,  or  the  vagina  is  injured.  If  such  an  injury  exists, 
radical  operation  is  of  course  demanded.  Always  use  a  catheter 
to  see  if  the  urine  is  bloody.  In  treating  a  pelvic  fracture 
endeavor  to  restore  the  parts  to  a  normal  position,  employing 
external  manipulation  and  inserting  a  finger  in  the  rectum  or 
in  the  vagina.  If  reduction  is  difficult,  give  ether.  Treat  as 
in  fracture  of  the  false  pelvis,  attending  carefully  to  visceral 
injuries.  In  fracture  with  separation  of  the  pubic  bones,  the 
bones  should  be  wired  together.  If  urinary  extravasation 
occurs,  perform  perineal  section.  If  there  are  signs  of  bowel 
injury,  perform  laparotomy.  All  visceral  injuries  are  treated 
by  general  rules.  Remove  the  dressings  in  six  weeks  and 
allow  the  patient  to  be  about  in  twelve  weeks.  In  fracture 
of  the  acetabulum,  if  the  limb  be  shortened,  give  ether  and 
reduce.  Treat  these  fractures  in  the  same  way  as  intracap- 
sular fractures  of  the  femur  (p.  478).  Fractures  of  the 
ischium  are  best  treated  by  the  application  of  a  pad  and 
adhesive  plaster,  and  rest  in  bed. 

Fractures  of  the  Sacrum. — This  bone  may  be  broken  by 


SPECIAL   FRACTURES.  443 

direct  force,  such  as  a  kick,  but  the  injur)-  is  rare.  The  sacral 
plexus  is  usually  injured,  and  if  it  is  paralysis  is  observed  in 
the  territor\'  of  its  branches. 

Symptoms. — The  symptoms  in  fracture  of  the  sacrum  are 
pain,  frequently  incontinence  of  feces  and  retention  of  urine, 
irregularity  of  the  sacral  spines,  ecchymosis,  and  crepitus. 
Crepitus  may  be  sought  for  Avith  one  hand  externally  and  a 
fincrer  of  the  other  hand  in  the  rectum.  The  lower  fragment 
pa?ses  forward  and  mav  obstruct  or  may  tear  the  rectum. 
Paralysis  may  be  found  in  the   area   of  distribution   of  the 

Treatment.— \\\  treating  fracture  of  the  sacrum  press  the 
fra<^ments  into  place  with  a  hand  externally  and  a  finger  in 
the"  rectum.  Do  not  plug  the  rectum.  Put  a  pad  over  the 
upper  fragment,  hold  it  with  plaster  or  a  binder,  place  the 
patient  recumbent  on  a  fracture-bed,  and  insert  a  large 
cushion  underneath  the  pad.  Some  surgeons  give  opium 
to  induce  constipation,  and  allow  a  fecal  support  to  accu- 
mulate in  the  rectum.  Use  a  clean  catheter  regularly,  and 
guard  against  bed-sores.  Union  occurs  in  about  four  weeks, 
when  the  dressing  can  be  removed.  The  patient  can  get 
about  again  in  six  weeks.  If  urinaiy  retention  persists  or 
if  intractable  bed-sores  form  after  eight  or  ten  weeks,  cut 
down  on  the  seat  of  injury  and  elevate  or  remove  the  portion 
of  bone  causing  pressure. 

Fractures  of  the  Coccyx.— The  cocc>-x  ma}-  be  broken 
or  be  separated  from  the  sacrum  by  a  fall.a  blow,  a  kick, 
or  the  straining  of  parturition.  Its  mobility  is  so  great, 
however,  that  it  does  not  often  break. 

Symptoms.— T\\^  chief  svmptom  of  fracture  of  the  coccyx 
is  pain,  which  is  much  aggravated  hx  sitting,  walking,  or 
strainincr  at  stool.  If  the  index  finger  is  inserted  m  the 
rectum  the  displaced  bone  is  felt ;  if  the  thumb  of  the  same 
hand  is  also  placed  externally,  a  rocking  motion  will  develop 
crepitus  and  preternatural  mobility. 

Treatment.— \\\  treating  fracture  of  the  coccyx  reduce  by 
external  pressure  and  bv  the  manipulations  of  a  finger  in 
the  rectum.  Put  the  patient  to  bed  and  obstruct  the  boAvels 
bv  opium  for  a  number  of  davs.  In  four  weeks  the  fracture 
should  be  united.  If  union  does  not  take  place,  defecation 
and  all  movements  of  the  coccyx  will  cause  excruciating 
pain  bv  pressure  on  the  last  sacral  nerve.  This  condition, 
known  as  "  coccvgodvnia."  demands  a  subcutaneous  division 
of  the  ner\^e  or  of  the  muscles  which  move  the  cocc}-x,  or  a 
resection  of  the  bone. 


444   DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS. 

Fractures  of  the  Vertebra.     (See  p.  710). 

Fractures  of  the  Skull.     (See  p.  6641. 

Fractures  of  the  Clavicle. — The  clavicle  is  more  often 
fractured  than  any  other  bone.  The  fracture  may  occur  at 
any  age,  but  is  commonest  before  the  sixth  year  (Hulke 
says  one-half  of  the  recorded  casesj.  It  may  be  simple,  mul- 
tiple, comminuted,  oblique,  transverse,  complete,  incomplete, 
or,  very  rarely,  compound.  Both  clavicles  may  be  broken. 
Fractures  are  most  apt  to  occur  just  external  to  the  middle, 
at  the  point  where  the  inner  or  large  cur\'e  meets  the  outer 
or  small  curve,  at  which  junction  the  bone  is  at  its  smallest 
diameter.  Fractures  of  the  acromial  end  are  more  frequent 
than  fractures  of  the  sternal  end,  and  less  frequent  than  fract- 
ures of  the  shaft.  The  causes  of  fracture  of  the  clavicle  are 
direct  violence,  indirect  violence,  and,  very  rarely,  the  con- 
tractions of  "  the  deltoid  and  clavicular  fibers  of  the  great 
pectoral "  (Treves,  from  Polaillon). 

Fractures  of  the  shaft  are  usually  due  to  indirect  violence, 
as  falls  upon  the  shoulder  or  upon  the  outstretched  hand. 
In  the  latter  accident,  which  is  the  usual  mode  of  origin,  the 
concussion  of  the  fall  travels  up  and  the  body-weight  travels 
down,  and  these  two  forces  compress  the  bone,  which  snaps 
at  its  weakest  point.  Fractures  from  indirect  force  are 
oblique,  and  in  children  are  of  the  green-stick  form.  Fract- 
ures from  direct  force  are  usually  transverse,  and  are  occa- 
sionally comminuted.  Fractures  from  muscular  action  have 
been  recorded  (Rubini  the  tenor,  recorded  by  Melay). 

Svniptonis. — In  fracture  of  the  shaft  of  the  clavicle  the  atti- 
tude of  the  patient  is  peculiar.  He  supports  the  elbow  or  wrist 
of  the  injured  side  with  the  hand  of  the  sound  side,  and  also 
pulls  the  extremity  against  the  chest ;  the  head  is  turned  down 
toward  the  shoulder  of  the  damaged  side,  as  if  tr}ang  to 
listen  to  something  in  the  joint,  thus  relaxing  the  pull  of 
the  sternocleidomastoid  muscle  upon  the  inner  fragment. 
The  shoulder  is  nearer  the  sternum,  on  a  lower  level,  and 
farther  front  than  that  of  the  sound  side.  Loss  of  func- 
tion is  shown  by  inability  to  abduct  the  arm.  Considerable 
pain  exists,  which  is  increased  by  motion,  by  pressure,  and 
by  hanging  down  the  extremity  without  support. 

The  deformity  above  noted  is  described  by  stating  that 
the  shoulder  goes  downward,  inward,  and  forward  (d.  i.  f.). 
The  dozunward  deformity  is  chiefly  due  to  the  weight  of  the' 
arm,  which  pulls  down  the  unsupported  outer  fragment,  and 
is  contributed  to  by  the  action  of  the  pectoralis  minor 
muscle.     The  inward  deformity  is  chiefly  due  to  the  con- 


SPECIAL    FRACTURES.  445 

traction  of  the  pectoralis  minor  and  subclavius  muscles 
assisted  by  the  action  of  the  pectorahs  major.  T\\tforii'ard 
deformit},'  is  due  to  rotation  of  the  outer  fragment,  which  is 
brought  about  by  the  serratus  magnus  muscle  carrying  the 
scapula  forward.  In  this  deformity,  the  inner  end  of  the 
outer  fragment  is  below  and  behind  the  outer  end  of  the 
inner  fragment,  which  overrides  it.  The  inner  fragment, 
though  pulled  on  by  the  sternomastoid  and  relatively  higher 
than  the  outer  fragment,  is  really  but  little,  if  at  all,  elevated, 
marked  elevation  being  prevented  by  the  attachment  of  the 
rhomboid  ligament.  After  noting  the  deformity,  detect  with 
the  finger  the  irregularity  of  bony  contour.  Examine  for 
preternatural  mobility  and  crepitus  by  raising  and  throwing 
back  the  shoulder.  In  looking  for  these  signs  in  children  it 
is  to  be  remembered  that  the  fracture  is  probably  incomplete. 
The  prognosis  is  good,  the  bone  uniting,  but  alwa}'s  with 
some  shortening  and  inequality. 

Complications. — Fractures  of  the  shaft  are  rareh'  compound, 
because  the  sharp  end  of  the  outer  fragment  passes  back- 
ward and  because  of  the  free  play  the  skin  makes  o\-er  the 
bone  (Pickering  Pick).  Both  clavicles  may  be  broken.  In 
fractures  from  direct  force  deeper  structures  may  be  injured 
by  fragments.  Thus,  injun,^  of  the  brachial  plexus  will 
induce  paralysis.  Injur\'  of  the  vein  or  arter\'  may  occur. 
Ribs  ma}'  be  broken  at  the  same  time. 

Trcatuicjit. — In  treating  a  fracture  of  the  shaft  correct  the 
deformit}''  as  soon  as  possible  b}-  throwing  the  shoulder 
upward,  outward,  and  backward.  If  the  patient  is  a  girl, 
it  is  desirable  to  minimize  the  deformity.  Place  her  upon 
her  back  on  a  hard  bed,  with  a  small  pillow  under  her  head, 
a  firm  and  narrow  cushion  between  the  shoulders,  a  bag 
of  shot  resting  over  the  seat  of  fracture,  and  the  forearm 
h'ing  on  the  front  of  the  chest,  the  arm  being  held  to 
the  side  by  a  sand-bag.  In  three  weeks  there  will  be  union, 
practical^  without  deformity.  In  a  child  with  an  incomplete 
fracture  a  handkerchief  sling  for  the  forearm,  worn  three 
weeks,  is  all  that  is  needed.  In  complete  fracture  the 
Velpeau  bandage  is  efficient.  Before  applying  it,  place 
lint  around  the  chest  and  cotton  over  the  elbow.  Change 
the  bandage  every  day  for  the  first  week,  and  after  that 
period  even,^  third  da}^  Each  time  it  is  changed  rub  the 
-skin  with  alcohol,  ethereal  soap,  or  soap  liniment,  dr}^  care- 
fully, and  examine  for  excoriations  ;  if  an}'  are  found,  they 
are  anointed  with  zinc  ointment  before  the  dressing  is  reap- 
plied.    The  dressing  is  permanent!}'  removed  at  the  end  of 


446   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 


Fig.  122. — Fox's  apparatus  for  fractured  clavicle. 


four  weeks,  the  arm  being  worn  in  a  .sling  for  another  week. 
The   classical   apparatus  of    Uesault    is    now    rarely    used. 

The  posterior  figure-of-8 
bandage  associated  with 
the  second  roller  of  De- 
sault,  some  turns  being 
made  from  the  elbow  of  the 
injured  side  to  the  shoul- 
der of  the  sound  side, 
can  be  used  in  cases  in 
which  the  forward  deform- 
ity is  apt  to  return.  The 
apparatus  of  Fox,  which 
is  very  useful,  consists  of  a 
pad  for  the  axilla,  a  sling 
for  the  forearm,  and  a  ring 
for  the  opposite  shoulder, 
to  which  ring  are  tied  the 
tapes'  from  both  the  pad 
and  the  sling  (Fig.  122). 
The  dressing  of  Moore  of  Rochester  is  valuable  in  an 
emergency.  It  consists  of  a  piece  of  cotton  cloth,  two  yards 
long,  and  folded  like  a  cra- 
vat until  it  is  eight  inches 
in  width  at  the  middle.  The 
center  of  the  bandage  rests 
upon  the  elbow,  the  poste- 
rior tail  is  carried  across 
the  front  of  the  shoulder 
of  the  injured  side.  The 
forearm  is  at  an  acute  angle 
with  the  arm,  and  the  other 
end  of  the  bandage  is  car- 
ried across  the  forearm, 
across  the  back  over  the 
opposite  shoulder,  and 
around  the  axilla,  where 
the  extremities  are  stitched  together.  The  forearm  is  sus- 
pended in  a  bandage  sling  (S.  D.  Gross).  The  four-tailed 
bandage  is  preferred  by  Pick.  Sayre's  dressing  has  many 
advocates  (Fig.  123).  For  this  there  are  required  two  pieces 
of  rubber  plaster,  each  piece  being  three  inches  wide  and 
sufficiently  long  to  go  around  the  chest  one  and  a  half  times. 
The  end  of  one  piece  encircles  the  arm  of  the  injured  side 
just  below  the  arm-pit;  the  plaster  strip  is  pulled  across  the 


Fig.  123. — Sayre's  adhesive-plaster  dressing 
for  fracture  of  the  clavicle  (Stimson)  :  y^,  first 
piece  ;   B,  second  piece. 


SPECIAL   FRACTURES.  447 

back  to  the  other  side,  to  the  front  of  the  cliest,  and  returns 
again  to  the  middle  of  the  back.  This  procedure  pulLs  the 
elbow  back  and  throws  the  shoulder  out.  The  hand  of  the 
injured  side  is  placed  on  the  breast  of  the  opposite  side,  cot- 
ton being  interposed,  and  the  second  strip  of  plaster  runs 
from  the  elbow  of  the  injured  side  and  the  opposite  shoulder, 
front,  around,  and  back,  pressing  the  elbow  forward,  upward, 
and  inward.  If  the  fragments  cannot  be  coaptated,  sterilize 
the  parts,  administer  ether,  incise,  clear  away  the  muscle 
from  between  the  fragments,  saw  the  ends,  bore  each  end 
and  hold  them  in  contact  by  means  of  kangaroo-tendon  or 
silver  wire.  The  same  procedure  should  be  pursued  when 
a  fracture  is  compound  or  threatens  to  become  so.  In  three 
cases  in  the  Jefferson  Medical  College  Hospital  the  author 
wired  the  bones  with  excellent  results. 

In  any  fracture,  if  signs  indicate  pressure  upon  vessels  or 
nerves,  or  if  the  fragment  has  penetrated  or  seems  liable  to 
penetrate  the  skin,  incise,  lift  the  fragments  into  place  and  wire 
them.  If  the  patient  refuses  this  operation,  put  him  to  bed 
and  abduct  the  arm.  If  a  vessel  is  injured,  operation  is  im- 
peratively necessary.  After  removing  the  dressings,  if  the 
shoulder  is  found  to  be  stiff,  make  passive  movements  daily ; 
if  these  fail,  move  the  joint  forcibly  after  giving  ether  or  nitrous 
oxid. 

Fractures  of  the  acromial  end  of  the  clavicle  are  due  to 
direct  force.  If  the  fracture  is  between  the  two  coracocla- 
vicular  ligaments,  deformity  is  very  slight,  crepitus  is  elicited 
by  manipulating  with  the  fingers,  and  pain  exists,  but  loss 
of  function  is  not  markedly  manifest  unless  it  is  due  to  pain. 
These  fractures  are  treated  by  interposing  cotton  between 
the  arm  and  the  side,  binding  the  arm  to  the  side  with  the  sec- 
ond roller  of  Desault,  and  hanging  tHe  hand  in  a  sling.  In 
fractures  external  to  the  ligaments  crepitus  is  manifest  on 
moving  the  shoulder,  the  outline  of  the  bone  is  irregular, 
severe  pain  is  developed  by  movement,  and  deformity  is  pro- 
nounced. The  deformity  is  due  to  the  serratus  magnus 
muscle  rotating  the  scapula  forward,  the  inner  end  of  the 
outer  fragment  of  the  clavicle  often  coming  in  contact  with 
the  anterior  surface  of  the  outer  portion  of  the  inner  fragment. 
Fracture  of  the  acromial  end  of  the  clavicle  is  reduced  by 
pulling  both  of  the  shoulders  strongly  backward,  and  it  is 
kept  reduced  by  the  use  of  a  posterior  figure-of-8  bandage. 
In  fracture  external  to  the  ligaments  the  displacement  fre- 
quently cannot  be   corrected  by  position  and  manipulation. 


448   DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS. 

Such  cases  demand  incision  and  wiring.     In  either  variety 
of  fracture  the  dressings  are  worn  for  four  weeks. 

In  children,  if  it  is  found  difficult  to  immobilize  the  parts, 
the  most  satisfactory  result  is  obtained  by  the  application  of 
the  Velpeau  bandage,  which  is  to  be  overlaid  by  a  plaster 
bandage. 

Fractures  of  the  sternal  end  of  the  clavicle  are  very  rare. 
They  are  caused  by  either  direct  or  indirect  force.  In  such 
a  fracture  there  are  found  crepitus,  projection  at  the  seat  of 
fracture,  rigidity  of  the  sternomastoid  muscle,  and  shortening 
of  the  clavicle.  The  inner  end  of  the  outer  fragment  always 
passes  forward,  and  often  also  downward  and  inward.  Reduce 
these  fractures  by  pulling  the  shoulders  back,  and  treat  them 
by  means  of  the  posterior  figure-of-8  bandage  worn  for  four 
weeks.     Wiring  may  be  necessary. 

Fractures  of  the  Scapula. — This  bone  is  not  often  broken, 
as  it  rests  upon  thick  muscles  and  elastic  ribs;  it  is  freely 
movable,  and  it  has  attached  to  it  a  bone  which  easily  breaks. 

Fractures  of  the  Body. — These  are  due  to  direct  violence. 
The  symptoms  are  pain  (which  becomes  agonizing  on  attempt- 
ing to  rotate  the  shoulder-blade),  ecchymosis,  and  swelling. 
Crepitus  is  sought  for  by  placing  the  hand  over  the  bone  and 
making  movements  of  the  arm;  also  by  holding  the  point 
of  the  shoulder  and  lifting  up  the  lower  angle  of  the  bone. 
The  latter  plan  may  develop  mobility.  The  spine  of  the 
scapula  is  uneven  only  when  it  itself  is  fractured.  Examine 
for  unevenness  of  the  vertebral  border.  In  fractures  of  the 
body  of  the  scapula  a  shoulder-cap  is  applied,  a  gutta-percha 
splint  is  moulded  over  the  scapula,  the  arm  is  bound  to  the 
side,  and  the  hand  is  carried  in  a  sling.  The  apparatus  is 
worn  for  four  weeks. 

Fractures  of  the  spine  of  the  scapula  are  treated  as  are 
fractures  of  the  body  of  the  bone,  and  for  the  same  time. 

Fractures  of  the  Neck. — Fracture  of  the  anatomical  neck 
has  not  been  proved  to  exist.  Fracture  of  the  stirgical  neck 
is  evinced  by  flattening  of  the  shoulder,  prominence  of  the 
acromion,  and  a  lump  in  the  axilla,  crepitus  being  developed 
by  pressing  the  axillary  prominence  upward  and  backward. 
The  deformity  is  reduced  with  ease,  but  it  at  once  recurs.  It 
is  treated  by  placing  a  pad  in  the  axilla,  a  shoulder-cap  on 
the  shoulder,  applying  the  second  roller  of  Desault,  and  sup- 
porting the  forearm  and  elbow  in  a  sling.  A  Velpeau  dress- 
ing can  be  used,  associated  with  a  folded  tow'el  in  the  axilla. 
The  dressing  is  to  be  worn  for  five  weeks. 

Fractures  of  the  glenoid  cavity,  which  are  not  very  un- 


SPECIAL    F/^ACTCRES.  449 

usual,  may  occur  with  or  without  dislocation.  Fracture  of 
this  region  arises  from  direct  force  applied  to  the  shoulder. 
The  existence  of  this  fracture  is  determined  by  excluding 
fractures  of  other  bones  and  b}^  detecting  crepitus  when  the 
arm  is  at  a  right  angle  to  the  bod}-  and  the  humerus  is 
pushed  against  the  glenoid  cavity,  the  crepitus  not  being  found 
when  the  arm  hangs  by  the  side. 

Trcafineiit  is  by  the  second  roller  of  Desault  and  a 
forearm  sling  worn  for  four  weeks  ;  careful  passive  move- 
ments limit  ankylosis.  If  ankylosis  occurs,  adhesions  must 
be  broken  up  while  the  patient  is  under  ether  or  nitrous 
oxid. 

Fractures  of  the  acromion  process  are  often  met  with  as 
the  result  of  direct  violence.  The  existence  of  fracture  of 
the  acromion  is  indicated  b\'  pain,  b}^  inabilit}'  to  abduct  the 
arm,  by  flattening  of  the  shoulder,  by  sudden  lowering  of 
the  point  of  the  shoulder,  by  mobilit\^  and  by  crepitus.  To 
treat  a  case  of  this  kind,  put  a  large  pad  in  the  axilla  with 
the  base  down,  bind  the  arm  over  the  pad  with  the  second 
roller  of  Desault,  Hfting  the  elbow  with  turns  of  the  roller 
carried  over  it  and  the  opposite  shoulder,  thus  splinting  the 
bone  in  place  by  the  head  of  the  humerus  pushing  against 
the  coraco -acromial  ligaments.  The  dressing  is  to  be  worn 
for  four  weeks. 

Fractures  of  the  coracoid  process  rareh^  happen  alone, 
and  may  arise  from  direct  force  or  from  muscular  action. 
But  little  displacement  is  found.  Crepitus  and  mobilit}'  are 
usualh'  detected.  Inability  to  shrug  the  shoulder  inward  was 
pointed  out  as  a  symptom  by  Byers.  Such  a  case  is  well 
treated  b}'  a  Velpeau  bandage,  which  is  to  be  worn  for  four 
weeks. 

Fractures  of  the  humerus  are  divided  into  (i)  fractures 
of  the  upper  extremit}- ;  (2)  fractures  of  the  shaft;  and  (3) 
fractures  of  the  lower  extremity.  In  examining  any  fracture 
of  the  humerus,  feel  at  once  for  the  pulse,  so  as  to  ascertain 
if  the  arter}^  has  been  torn ;  in  any  fracture  near  the  head  of 
the  humerus  be  certain  that  there  is  no  dislocation. 

I.  Fractures  of  the  upper  extremity  include  {li)  fractures 
of  the  anatomical  neck ;  {b)  fractures  of  the  surgical  neck ; 
{c)  fractures  of  the  head,  oblique  and  longitudinal;  and  {d) 
separation  of  the  upper  epiphysis. 

Fractures  of  the  Anatomical  Neck  of  the  Humerus. — 
The  anatomical  neck  is  the  constricted  circumference  of  the 
articular  surface,  and  fractures  of  it,  though  rare,  do  occur, 
especially  in  the  aged.     The  line  of  fracture  in  some  cases 

29 


45 O    DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

follows  the  insertion  of  the  capsule,  in  others  it  is  entirely 
within  the  capsule,  but  in  most  it  is  without  the  capsule 
above  and  within  the  capsule  below;  hence  the  term  "  intra- 
capsular "  is  rarely  correct  as  a  designation.  Such  a  fract- 
ure may  be  impacted.  The  cmise  is  direct  violence  or  a  fal 
or  a  blow  upon  the  elbow  when  the  arm  is  abducted.  Pol- 
loson  of  Lyons  ^  has  reported  a  case  due  to  muscular  action. 
The  patient  died  in  eclampsia,  and  at  the  necropsy  it  was  found 
that  both  humeral  heads  were  fractured  and  impacted.  The 
fractures  must  have  been  produced  by  the  muscles  throwing 
the  heads  of  the  bones  violently  against  the  glenoid  cavities, 
probably  by  adduction. 

Symptoms. — The  symptoms  in  fracture  of  the  anatomical 
neck  are  pain,  swelling,  ecchymosis,  slight  irregularity  of  the 
shoulder  (which  irregularity  is  soon  hidden  by  tumefaction), 
and  inability  to  actively  abduct  the  arm.  Deformity,  as 
a  rule,  is  slight  or  is  absent,  because  the  capsule  is  rarely  en- 
tirely torn  from  the  lower  fragment.  If  deformity  exists,  it  is 
due  to  the  muscles  inserted  on  the  bicipital  groove  and  to  the 
coracobrachialis,  which  pull  the  lower  fragment  inward  and 
forward.  Treves  says  that  a  tear  of  the  reflected  fibers  of  the 
capsule  leads  to  subsequent  necrosis,  because  this  joint  has 
no  ligamentum  teres.  In  some  cases  impaction  occurs,  the 
upper  fragment  impacting  in  the  lower.  In  this  condition  there 
are  very  slight  shortening  and  trivial  shoulder-flattening,  no 
crepitus  unless  the  tuberosity  is  broken  off.  and,  as  Erichsen 
says,  the  head  of  the  bone,  while  it  can  be  felt  through  the 
axilla,  is  not  in  the  axis  of  the  limb. 

The  prognosis  of  fracture  of  the  anatomical  neck  is  usually 
good  for  bony  union  (Hamilton,  Pick,  and  R.  W.  Smith),  but 
a  stiff  joint  is  apt  to  result. 

Treatment. — Some  surgeons  treat  this  fracture  by  simply 
hanging  the  wrist  in  a  sling  and  suspending  a  bag  of  shot  from 
the  elbow  to  make  extension.  The  usual  plan  of  treatment  is 
as  follows  :  flex  the  arm  to  a  right  angle  wath  the  body,  and 
carry  up  from  the  base  of  the  fingers  to  above  the  elbow  the 
turns  of  a  spiral  reversed  bandage.  Interpose  lint  between  the 
arm  and  the  side,  and  place  a  folded  towel  or  a  small  pad  in  the 
axilla,  tying  the  tapes  over  the  opposite  shoulder.  Mould  a 
shoulder-cap  (PI.  6,  Fig.  8)  upon  the  outer  aspect  of  the  arm 
and  upon  the  shoulder.  This  cap,  which  is  made^of  paste- 
board or  of  felt,  should  reach  below  the  insertion  of  the  deltoid, 
cover  one-half  the  circumference  of  the  arm,  and  is  to  be 
padded  with  cotton.     The  arm  with  the  shoulder-cap  is  fixed 

^  Rev.  de  Chir.,  vol.  viii.,  l888. 


SPLINTS. 


Plate  6. 


I  Fractur"-box  2.  Double  Inclined  Plane  Fracture-box.  3-  J^^-^up  (unfolded)  4.  Jaw-cup 
(folded)  5.  Anterior  Angular  Splint.  6.  Internal  Angular  Splint.  7.  Bond  Splint.  8.  Shoulder-cap. 
fDupuytren  Splint  in  Pott's  Fracture.  .0.  Agnew  Splint  for  Fracture  of  the  Metacarpus,  xx.  Agnew 
SpHnt  for  Fracture  of  the  Patella.  z2.  Agnew  Splint  applied.  X3.  Strapping  the  Chest  m  Fractured 
Ribs  X4.  Extension  Apparatus  in  Fracture  of  the  Femur.  X5,  x6.  Adhesive  Strips  for  Extension 
Apparatus. 


SPECIAL    FRACTURES.  451 

to  the  side  by  the  second  roller  of  Dcsault,  and  the  wrist  is 
hun<;-  in  a  sling.  The  edges  of  the  bandage  should  be  stitched 
together.  This  apparatus  is  changed  daily  for  the  first  few 
days,  the  body  and  arm  being  rubbed  at  each  change  with 
alcohol,  soap  liniment  or  ethereal  soap.  After  this  period  a 
change  every  third  or  fourth  day  is  often  enough.  Passive 
motion  is  begun  at  the  end  of  four  weeks,  and  the  dressings 
are  removed  at  the  end  of  six  weeks.  In  impacted  fracture 
do  not  pull  apart  the  impaction,  but  apply  a  cap  to  the  shoul- 
der and  fix  the  arm  to  the  side  for  five  weeks.  No  pad  is 
used.     The  fracture  unites  with  deformity. 

Fractures  of  the  Surgical  Neck  of  the  Humerus. — The 
surgical  neck  is  the  constricted  portion  of  bone  between  the 
tuberosities  and  the  upper  line  of  the  insertion  of  the  muscles 
on  the  bicipital  groove.  Fractures  in  this  region  are  usually 
transverse,  but  they  may  be  oblique.  The  canses  are— direct 
force  almost  always  ;  indirect  force  occasionally ;  and  mus- 
cular action  in  rare  instances. 

Svinptoins. — The  symptoms  in  fracture  of  the  surgical  neck 
are— pain  running  into  the  fingers  from  pressure  upon  the 
brachial  plexus ;  crepitus  and  mobility  on  extension ;  and 
flattening,  which  differs  from  the  flattening  of  dislocation  in 
that  it  occurs  farther  below  the  acromion  and  that  this  proc- 
ess is  not  so  prominent.  Shortening  to  the  extent  of  an 
inch  is  noted.  The  head  of  the  bone  can  be  felt  in  the  gle- 
noid cavity,  but  it  does  not  move  on  rotating  the  arm.  The 
upper  end  of  the  lower  fragment  is  felt  and  moves  on  rotat- 
ing the  arm.  The  displacement  is  pronounced.  The  lower 
fragment  is  pulled  upwafd  by  the  deltoid,  biceps,  coraco- 
brachialis,  and  triceps  ;  inward  by  the  muscles  of  the  bicipital 
groove ;  and  forward  by  the  great  pectoral ;  thus,  the  upper 
end  of  the  lower  fragment  projects  into  the  axilla,  and  the 
elbow  lies  from  the  side  and  backward.  Pean  holds  that  the 
violence  drives  the  lower  fragment  forward.  The  upper  frag- 
ment is  abducted  and  rotated  outward,  which  position  is  due, 
it  is  generally  taught,  to  the  action  of  the  supraspinatus,  in- 
fraspinatus, and  teres  minor  muscles.  In  some  cases  dis- 
placement is  forward,  and  in  other  cases  it  is  not  obvious. 
The  lower  fragment  may  impact  into  the  upper,  in  which  case 
the  symptoms  are  obscure  and  the  diagnosis  is  made  by  ex- 
clusion. If  the  impaction  is  solid  and  complete,  there  are 
the  history  of  direct  force,  the  impaired  movements,  the 
slight  deformity,  and  the  absence  of  crepitus.  In  all  fract- 
ures of  the  upper  end  of  the  humerus  the  distinction  can  be 
made  from  dislocation  by  feeling  the  head  of  the  bone  under 


452   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 


Fig  124  — Internal  angular  splint  and 
shoulder  cap  in  fracture  of  the  surgical 
neck  uf  the  humerus. 


124).     The  dressing  is  to 


the  acromion  and  by  noting  that  it  does  not  move  on  rotating 
the  arm. 

The  /prognosis  of  these  fractures  is  good. 

Treainicnt. — In  treating  a  case 
of  fracture  of  the  surgical  neck, 
reduce  by  traction  and  manipula- 
tion ;  if  there  is  an  impaction,  pull 
it  apart.    Take  an  internal  angu- 
lar splint  (PI.  6,  Fig.  6)  and  pad 
it  well,  putting  on  extra  padding 
at   the    points    that    are   to    rest 
against  the  palm,  the  inner  con- 
dyle, and  the  axillary  folds.     Lay 
the   arm    and    pronated    forearm 
upon  the  splint.    Apply  a  padded 
shoulder-cap.     Fix  the  splint  and 
cap  in  place  with  a  spiral  reversed 
bandage    terminating    as    a  spica 
of  the    shoulder,   and    hang    the 
hand  or  forearm  in  a  sling  (Fig. 
be  worn  for  five  weeks,  and  the 
rules  to  be  followed  in 
changing  it  are  the  same 
as  in  fractures  of  the  ana- 
tomical neck.     Motions 
are  to  be  made  after  four 
weeks   to   amend    stiff- 
ness.    Another  plan  of 
treatment   is    the    same 
as    for   fracture    of   the 
anatomical    neck,    sup- 
porting the    wrist  only 
in  a  sling  so  as  to  get 
the  extending  weight  of 
the  elbow,  increasing  this 
weight    in    some    cases 
by  hanging  to  the  elbov\^ 
a  bag  of  shot.     In  rare 
cases — those  with  strong 
anterior    projection    of 
the   lower   end    of    the 
upper  fragment — apply 

Fig.  125.— Apparatus  for  fracture  of  the  humerus  at  Qnff^ri'r,r  anmilar 

any  point  above  the  condyles.  ^n  anteHOr  aUgUiar 

splint.     In    some    cases 
where  the  deformity  strongly  tends  to  recur  support  by  a 


SPECIAL    FRACTURES.  453 

plaster-of-Paris  trough  on  the  back  and  sides  of  arm  and 
shoulder  (Fig.  125),  or  maintain  extension  by  weights  and 
pulleys,  the  patient  being  kept  in  bed  (Stimson). 

Longitudinal  and  Oblique  Fractures  of  the  Head  of  the 
Humerus. — By  this  term  may  be  designated  separation  of 
the  o-reat  tuberosity,  or  separation  of  a  portion  of  the  articular 
surface,  together  with  the  great  tuberosity,  from  the  shaft 
and  lesser  tuberosity  (Pickering  Pick,  Guthrie,  and  Ogston). 
The  cause  is  direct  violence  to  the  front  of  the  shoulder. 

Symptoms. — The  symptoms  in  longitudinal  and  oblique 
fracture  of  the  head  are  broadening  and  flattening  of  the 
shoulder  with  projection  of  the  acromion.  The  upper  frag- 
ment passes  upward  and  outward,  and  the  lower  fragment 
passes  upward  and  inward  to  rest  on  the  margin  of  the 
glenoid  cavity  below  the  coracoid  process.  The  elbow  is 
drawn  from  the  side,  there  is  some  shortening,  and  the 
patient  cannot  abduct  his  arm.  If  the  elbow  be  grasped  and 
held  to  the  side  and  the  arm  be  rotated  while  the  other 
hand  grasps  the  upper  fragment,  crepitus  is  very  positive. 
Examination  develops  wide  separation  of  the  fragments. 
The  deformity  cannot  be  entirely  corrected,  because  the 
biceps  tendon'  usually  gets  between  the  fragments  (Ogston), 
but  a  useful  limb  can  usually  be  obtained. 

Treatment. — The  plan  which  gives  the  best  result  in  treat- 
ing longitudinal  and  oblique  fracture  of  the  head  of  the  bone 
is  to  place  the  patient  on  his  back  upon  a  hard  bed  with  a 
small  firm  pillow  under  his  head,  abduct  the  arm  above  the 
head,  rotate  it  outward  so  that  the  back  of  the  hand  rests 
on  the  bed,  and  hold  it  in  place  by  sand-bags.  This  position 
should  be  maintained  for  three  weeks,  at  the  end  of  which 
period  the  fracture  can  be  dressed  for  three  weeks  more  as  a 
fracture  of  the  anatomical  neck.  If  the  patient  refuses  to  go 
to  bed,  treat  the  injury  as  a  fracture  of  the  anatomical  neck, 
padding  well  over  the  tuberosities.  The  dressings  should  be 
worn  for  six  weeks,  passive  motion  being  made  after  four 
weeks.  In  all  the  above  injuries — in  fact,  in  all  fractures  of 
the  humerus — feel  at  once  for  the  pulse,  to  see  if  the  artery 
has  been  torn. 

Separation  of  the  Upper  Epiphysis. — The  epiph)-sis  is 
united  during  the  twentieth  year,  its  separation  being  a  rare 
accident  and  being  produced  by  direct  force. 

Symptoms. — The  chief  symptom  in  separation  of  the  upper 
epiphysis  is  projection  of  the  upper  end  of  the  lower  frag- 
ment inward,  forward,  and  upward  beneath  the  coracoid,  and 
consequently  a  projection  of  the  elbow  backward  and  from 


454   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

the  side.  If  the  lower  fragment  passes  forward  and  not 
inward,  the  elbow  simply  passes  back.  The  upper  end  of 
the  lower  fragment  is  smooth  and  convex.  Rotation  of  the 
shaft  develops  soft  crepitus  when  the  fragments  are  in 
contact. 

The  prognosis  is  good  for  bony  union,  though  the  future 
growth  of  the  limb  may  be  impaired. 

Treatment. — The  treatment  for  separation  of  the  upper 
epiphysis  is  a  pad  in  the  axilla,  a  shoulder-cap,  binding  the 
arm  to  the  side,  and  hanging  the  hand  in  a  sling.  Wear  the 
dressing  for  six  weeks. 

2.  Fractures  of  the  Shaft  of  the  Humerus. — Fracture 
of  the  shaft  of  the  humerus  is  a  very  common  accident. 
The  cause  is  usually  direct  violence,  such  as  a  blow.  The 
fracture  may  arise  from  indirect  violence,  such  as  a  fall  upon 
the  elbow.  Muscular  action  is  not  rarely  also  a  cause,  as 
in  throwing  a  ball,  in  catching  a  tree-limb  while  falling,  or  in 
turning  another's  wrist  as  a  test  of  strength  (Treves). 

The  symptoms  of  fracture  of  the  shaft  of  the  humerus  are 
pain,  swelling,  ecchymosis,  inability  to  move  the  arm,  mobility, 
and  distinct  crepitus.  Shortening  to  the  extent  of  three-fourths 
of  an  inch  occurs.  The  displacement  varies  with  the  situa- 
tion of  the  fracture  and  the  direction  of  the  force.  If  the 
fracture  is  above  the  insertion  of  the  deltoid,  the  lower  frag- 
ment is  pulled  up  by  the  triceps,  biceps,  and  deltoid,  and 
pulled  out  by  the  deltoid,  and  the  upper  fragment  is  pulled 
inward  by  the  arm-pit  muscles.  In  fracture  below  the  del- 
toid this  muscle  is  apt  to  pull  the  lower  end  of  the  upper 
fragment  outward,  while  the  lower  fragment  passes  inward 
and  upward  because  of  the  action  of  the  biceps  and  triceps. 
Injury  of  the  musculospiral  nerve  sometimes  occurs.  The 
nerve  may  be  divided,  paralysis  occurring  in  the  muscles 
supplied  by  it  (drop-wrist),  or  it  may  be  bruised,  neuritis 
resulting.  In  some  cases  the  nerve  is  caught  in  and  com- 
pressed by  the  callus. 

The  prognosis  is  good,  but  the  fact  should  always  be 
remembered  that  ununited  fractures  are  commoner  in  the 
humerus  than  in  any  other  bone.  Treves  believes  this  to  be 
due  to  entanglement  of  muscle  between  the  fragments,  lack  of 
fixation  of  the  shoulder-joint,  and  imperfect  elbow-support. 
Hamilton  believes  that  it  is  due  to  the  facts  that  the  elbow 
soon  becomes  fixed  at  a  right  angle,  and  that  any  movement 
of  the  forearm  moves  the  seat  of  fracture,  and  not  the  elbow. 

Treatment. — Reduce  the  fracture  by  extension,  counter- 
extension,  and    manipulation.      Apply   an    internal    angular 


SPECIAL    FRACTURES. 


455 


Fig.    126. — Internal  angu.ar    splint    i 
fracture  of  the  shaft  of  the  humerus. 


splint  without  the  shoulder-cap  (Fig.  1 26).  If  deformity  is  not 
corrected,  associate  with  this  splint  three  short  humeral  splints 
instead  of  the  shoulder-cap  used  in 
fractures  near  the  shoulder-joint. 
Splints  are  to  be  worn  for  six 
weeks.  Passive  moxements  are 
not  to  be  made  until  the  fracture 
is  well  united  (after  six  weeks), 
for,  if  made  too  soon,  they  predis- 
pose to  non-union,  and,  as  no  joint 
is  in\'olved,  genuine  ank}'losis  will 
not  occur.  ]\Iany  surgeons  treat 
these  fractures  by  applpng  plas- 
ter-of-Paris  to  the  forearm  and 
the  ami  (the  elbow  being  flexed 
to  a  right  angle),  and  hanging 
a  weight  to  the  elbow.  Others 
apply  a  trough  to  the  arm  and 

forearm  (Fig.  125).  In  any  case  in  wliich  it  is  impossible 
to  obtain  and  maintain  correct  apposition  of  the  fragments 
cut  down  upon  them,  and  apply  sutures.  If  the  nene  is 
divided,  an  incision  must  be  made,  and  the  ner\-e  sutured 
and  the  bone  wired.  If  the  ner\-e  is  caught  in  the  callus, 
after  repair  has  taken  place  the  nerve  must  be  liberated  by 
chiselling  the  callus  away.  Neuritis  is  treated  by  blisters 
over  the  ner\^e,  the  use  of  the  descending  galvanic  current, 
and  the  administration  of  salicylate  of  ammonium. 

3.  Fractures  of  the  Lo"wer  Extremity  of  the  Humerus. 
— These  fractures  are  spoken  of  as  fractures  in,  or  in  the 
neighborhood  of,  the  elbow-joint,  and  they  include  {a)  fract- 
ures of  the  external  cond}-le ;  (/?)  fractures  of  the  internal 
condyle ;  [c)  fractures  of  the  internal  epicondyle ;  (^/)  fract- 
ures at  the  base  of  the  condyles ;  {c)  T-  or  Y-shaped  fract- 
ures ;  (/")  epiphyseal  separation;  and  (^)  fractures  of  the 
capitellum  and  trochlea.  There  may  be  more  than  one  of 
these  fractures,  or  there  may  be  also  a  dislocation  of  the 
humerus,  of  the  ulna,  or  of  both  bones.  Rarely  the  fracture 
is  compound. 

These  fractures  are  frequent  injuries.  They  are  rapidly 
followed  b}-  great  swelling,  and  the  diagnosis  is  often  ver}'- 
difficult.  In  most  cases,  when  possible,  the  .r-ray  should  be 
used  in  arri\-ing  at  a  diagnosis.  In  ever\^  case  in  which  the 
.r-ray  is  not  used,  and  in  most  cases  in  which  it  is,  the  sur- 
geon examines  the  parts  carefulh'  while  the  patient  is  under 
ether.     If  swelling  is  ver^^  great,  it  is  necessar}'  to  abate  it  in 


456   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

order  to  reach  any  conclusion  as  to  the  condition.  We  can 
bandage  the  arm,  rest  it  semiflexed  on  a  pillow,  and  apply 
evaporating  lotions  or  even  an  ice-bag  for  a  day  or  two,  or, 
what  is  better,  temporarily  diminish  the  swelling  by  Gerster's 
plan,  which  is  as  follows :  apply  an  Esmarch  bandage  from 
the  hand  to  well  above  the  seat  of  fracture ;  this  will  drive 
away  extra-articular  swelling  and  permit  of  thorough  exam- 
ination. It  is  a  great  advantage  to  have  the  patient  anesthe- 
tized, for  not  only  can  we  make  an  accurate  diagnosis,  but 
we  can  reduce  the  fracture  satisfactorily  and  apply  a  careful 
first  dressing. 

Fractures  of  the  External  Condyle  of  the  Humerus. — 
A  fracture  of  the  external  condyle  runs  into  the  joint  and 
the  capitellum  is  usually  broken  off.  Such  an  injury  occurs 
oftenest  in  children,  being  due  to  falling  on  the  hand ;  but  it 
may  occur  from  direct  force,  and  may  happen  to  adults. 

Symptoms. — The  symptoms  of  fracture  of  the  external 
condyle  are  severe  pain,  great  swelling,  and  crepitus  (found 
on  pressing  or  moving  the  condyle  and  on  rotating  the 
radius).  Mobility  may  also  be  discovered.  A  projection  is 
felt  on  the  outer  and  posterior  surface  of  the  elbow.  The 
forearm  is  semiflexed  and  supinated.  The  patient  cannot  use 
the  joint.  The  first  examination  should  be  made  under  ether 
unless  an  A'-ray  apparatus  is  accessible;  but  even  when  we 
have  a  skiagraph  of  the  part  the  first  dressing  should  be  put 
on  under  ether. 

Fractures  of  the  Inner  Epicondyle  of  the  Humerus. — 
The  inner  epicondyle  is  an  epiphysis  which  unites  during 
the  seventeenth  year.  It  not  infrequently  breaks  from  mus- 
cular action  or  from  direct  violence,  the  fracture  not  involving 
the  joint.  Crepitus  and  mobility  can  be  detected.  Displace- 
ment is  slight.     The  outer  epicondyle  is  never  fractured  alone. 

Fractures  of  the  Internal  Condyle  of  the  Humerus. — 
The  line  of  fracture  after  a  break  of  the  internal  condyle 
runs  into  the  joint,  to  the  trochlear  surface  of  the  humerus. 
The  cause  is  always  direct  violence. 

Symptoms. — In  fracture  of  the  internal  condyle  the  frag- 
ment, accompanied  by  the  ulna,  goes  upward  and  backward, 
and  when  the  forearm  is  extended  the  ulna  projects  poste- 
riorly, the  lower  end  of  the  humerus  being  felt  in  front.  The 
fragment  forms  a  projection  back  of  the  elbow.  Crepitus 
and  preternatural  mobility  can  be  found  if  swelling  is  not  too 
great.  Crepitus  is  detected  by  flexing  and  extending  the 
forearm.  The  space  between  the  condyles  is  broader  than 
normal,  and  the  forearm  takes  a  bend  toward  the  ulnar  side, 


SPECIAL   FRACTURES. 


457 


the  "  carrying  function  "  of  the  forearm  being  lost.  When  a 
person  carries  a  heavy  object,  such  as  a  bucket,  he  instinc- 
tiveh'  rests  the  inner  condyle  upon  the  pelvis,  and  the  normal 
deviation  of  the  forearm  outward  keeps  the  bucket  from 
striking  the  leg.  This  deviation  outward  when  the  inner 
condyle  rests  against  the  ilium  gives  us  the  carrj^ing  function. 
In  fracture  of  the  inner  condyle  the  broken  condyle  ascends 
and  the  "  carrying  function  "  is  lost  (Fig.  127). 


Fig.  127. — Diagram  to  exhibit  the  "  carrj-ing  function  "  of  the  forearm,  and  the  loss  of 
this  function  in  fracture  of  the  inner  condyle  of  the  humerus  :  a  and  /'  show  the  normal  rela- 
tion of  the  parts  when  carr^'ing ;  c  shows  the  alteration  of  axis  of  the  forearm  when  the  inner 
condyle  is  fractured,  what  is  known  as  gun-stock  deformity  resulting  (after  Allis). 

Fractures  at  the  Base  of  the  Condyles  of  the  Humerus. 

— A  fracture  in  this  region  is  just  above  the  olecranon  and  is 
on  a  higher  level  behind  than  in  front.  The  cause  is  direct 
force  acting  upon  the  olecranon. 

The  symptoms  are  loss  of  function  and  pain  from  injury  of 
the  median  or  ulnar  nerve.  Crepitus  and  mobilit}^  are  readily 
found.  The  lower  fragment  goes  backward  and  upward  by 
the  action  of  the  triceps,  biceps,  and  brachialis  anticus  muscle. 
The  lower  end  of  the  upper  fragment  projects  in  front  of  the 


458   DISEASES  AA'D   INJURIES   OE  BONES  AND  JOINTS. 


joint.  This  lesion  may  be  mistaken  for  dislocation  of  the 
bones  of  the  forearm  backward.  In  fracture  the  limb  is 
mobile  ;  in  dislocation  it  is  rigid.  In  fracture  the  deformity  is 
easily  reduced  and  strongly  tends  to  recur ;  in  dislocation 
the  deformity  is  reduced  with  difficulty  and  does  not  tend  to 
recur.  In  dislocation  there  is  shortening  of  the  forearm  but 
not  of  the  arm ;  in  fracture  there  is  shortening  of  the  arm 
but  not  of  the  forearm.  In  dislocation  there  is  a  smooth 
large  projection  below  the  crease  in  front  of  the  elbow ; 
in  fracture  there  is  a  sharp  projection  above  the  crease.  In 
fracture  there  is  crepitus  ;  in  dislocation  there  is  no  crepitus. 
The  diagnosis  can  usually  be  settled  by  the  Rontgen  rays. 
T-fractures  of  the  Humerus. — A  T- fracture  consists  of 
a  transverse  fracture  above  the  condyles  plus  a  vertical  fract- 
ure between  them.  The  cause  is  violent  direct  force  applied 
posteriorly. 

Symptoms. — The  symptoms  are  increase  in  breadth  of  the 
joint,  preternatural  mobility,  crepitus,  pain  and  swelling, 
mounting  up  of  the  inner  condyle  back  of  the  elbow  on  the 
inner  side,  and  of  the  outer  condyle  back  of  the  elbow  on  the 
outer  side.  The  forearm  is  semiflexed  and  supinated,  and  the 
carrying  function  is  lost. 

Prog-nosis  of  Fractures  In  or  Near  the  Elbow-joint. — 
In  many  fractures  it  is  difficult  or  impossible  to  obtain  reduc- 
tion, and  in  some  it  is  impossible  to  maintain  reduction.  Stim- 
son  is  undoubtedly  right  when  he  says  that  "in  intercondyloid 
fracture  with  marked  separation  there  is  no  practicable  means 
merely  to  maintain  reduction."^     The  prognosis  for  complete 

restoration  of  function  is  bad, 
and  in  most  of  these  fract- 
ures some  deformity  and 
considerable  stiffness  are  in- 
evitable. Ankylosis  partial 
or  complete  is  a  not  unusual 
sequence.  Ankylosis  may 
result  from  prolonged  im- 
mobilization, the  muscles 
contracting  and  becoming 
fibrous,  the  fascia  and  liga- 
ments about  the  joint  short- 
ening, the  capsule  shrinking 
and  thickening,  some  of  the 
cartilages  becoming  fibrous, 
and  the  joint  being  partly  obliterated.     It  may  result  from  ex- 


FiG.  128. — Anterior  angular  splint  for  fractures 
in  or  near  the  elbow-joint. 


'  Transactions  American  Surgical  Association,  vol.  ix. 


SPECIAL   FRACTURES.  459 

travasation  of  blood  into  the  joint  and  tendon-sheaths  with  sub- 
sequent formation  of  fibrous  tissue.  It  may  arise  from  the  or- 
ganization of  inflammatory  exudate  within  and  about  the  joint 
and  in  the  sheaths  of  muscles  and  tendons.  It  may  arise 
from  the  formation  of  an  excess  of  callus.  Bruns  claims  that 
in  fracture  in  the  joint  excess  of  callus  rarely  forms,  and  that 
masses  of  callus  form  chiefly  in  the  line  of  fracture  near  but 
not  in  a  joint.^  Excessive  callus-formation  is  sure  to  take 
place  if  reduction  is  not  thoroughly  accomplished  or  if  the 
fragments  are  not  well  immobilized  but  move  upon  each  other. 
A  mass  of  callus  in  or  about  a  joint  acts  like  a  stone  pushed 
into  the  crack  of  a  door — it  limits  or  prevents  motion. 

Treatment  of  Fractures  In  or  Near  the  Elbo"w-joint. — 
Thoroughly  set  the  fracture  while  the  patient  is  under  ether. 
It  is  advisable,  when  it  can  be  done  conveniently,  to  use  the 
,r-rays  to  confirm  the  diagnosis  and  to  use  them  again  after 
dressings  have  been  appUed,  to  be  sure  that  the  fracture 
remains  in  good  position.  Some  surgeons  advocate  dressing 
the  fracture  on  an  anterior  angular  splint,  the  forearm  being 
fully  supinated.  The  advantage  claimed  for  this  splint  is  that 
if  ankylosis  occurs  the  joint  is  in  a  position  to  be  useful, 
which  it  is  not  if  ankylosed  in  extension.  Some  deformity  is 
usually  apparent  after  treating  a  case  with  this  splint ;  the 
deformity  following  fracture  of  the  inner  condyle  is  not  cor- 
rected by  it,  but  if  the  splint  is  carefully  applied  the  result  is 
usually  a  useful  extremity.  The  splint  must  not  be  applied 
when  there  is  great  swelling,  and  swelling  must  be  removed 
by  resting  the  extremity  on  a  pillow,  the  elbow  being  semi- 
flexed, applying  evaporating  lotions  or  even  an  ice-bag, 
employing  massage,  and  gently  compressing  by  bandaging. 
In  some  cases  the  joint  should  be  aspirated.  In  order  to 
apply  this  dressing,  take  a  right-angled  splint  and  pad  its 
outer  surface,  being  careful  to  place  thick,  soft  pads  over  the 
convexity  which  will  press  in  front  of  the  elbow  and  over  each 
end  of  the  splint.  Fasten  the  upper  end  to  the  arm,  then 
make  extension  of  the  forearm,  and  if  the  fracture  is  found  to 
be  well  reduced,  fasten  the  hand  and  forearm  to  the  splint 
(Fig.  128).  If  the  hand  and  forearm  are  first  fixed  to  the 
splint,  there  will  be  no  extension  from  the  elbow  and  deform- 
ity will  result.  If  posterior  projection  exists, a  pasteboard  cup 
is  moulded  over  the  elbow.  The  extremity  is  hung  in  a  trian- 
gular sling.  At  night  the  extremity  is  kept  in  the  sling  or 
laid  on  a  pillow.  Every  third  or  fourth  day,  while  the  extrem- 
ity is  carefully  steadied,  the  splint  is  removed,  the  arm  and 

1  Max  Oberst,  in  Volkmann's  Sammlung  Vortrdge. 


460   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

forearm  well  rubbed  with  alcohol,  massaged,  and  the  splint 
reapplied.  The  splint  is  worn  for  four  weeks.  Some  sur- 
geons prefer  to  obtain  a  right-angled  position  of  the  elbow 
by  the  use  of  a  posterior  trough.  At  the  end  of  the  second 
week,  while  the  dressings  are  off,  slightly  flex  and  slightly 
extend  the  forearm,  and  slightly  pronate  it,  and  reapply  the 
splint.  At  the  end  of  the  third  week  repeat  this  maneuver, 
making  greater  movements.  In  the  middle  of  the  fourth 
week  and  at  the  end  of  the  fourth  week  do  it  again,  and  flex 
and  extend  as  much  as  possible.  Very  early  and  very  fre- 
quent passive  motion  is  objectionable,  as  it  leads  to  overpro- 
duction of  callus  and  ankylosis,  but  passive  motion  as  above 
described  is  imperatively  necessary.  Many  surgeons  at  the 
end  of  the  second  week  apply  a  Stromeyer  spHnt,  which  per- 
mits the  patient  and  the  surgeon  to  make  some  motion  by 
means  of  the  screw  without  removing  the  dressings.  In  veiy 
stout  people  an  anterior  angular  splint  will  not  stay  in  place. 
In  such  a  case  the  forearm  may  be  placed  at  a  right  angle 
to  the  arm  and  plaster-of- Paris  be  used.  After  the  dressings 
are  removed  employ  passive  motion,  massage,  hot  and  cold 
douches,  inunctions  of  ichthyol  or  mercurial  ointment,  iodin 
locally,  corrosive  sublimate  and  iodid  of  potassium  internally, 
and  direct  the  patient  to  systematically  use  the  arm.  If  in 
any  case  after  four  weeks  non-union  exists,  put  up  the  arm 
in  a  plaster  splint  for  three  or  four  weeks  more. 

Allis  warmly  advocates  treatment  in  extension.  He  holds 
that  the  extended  position  secures  the  best  circulation,  and 
if  either  condyle  is  unbroken  gives  us  a  natural  splint.  Fur- 
thermore, in  fractures  of  the  inner  condyle,  it  restores  the 
carrying  function,  which  the  flexed  position  does  not  do. 
For  one  week  after  the  accident  the  patient  stays  in  bed, 
with  his  arm  extended  upon  a  pillow.  After  swelling  sub- 
sides the  limb  is  wrapped  firmly  in  a  spiral  flannel  bandage 
and  plaster  is  rubbed  in  or  the  bandage  is  covered  with  adhe- 
sive plaster. 

Some  surgeons  extend  the  limb  and  apply  an  ordinary 
plaster  bandage,  and  in  about  three  weeks  substitute  an  ante- 
rior angular  splint.  The  trouble  with  treatment  in  exten- 
sion is  that  if  ankylosis  ensues  the  limb  is  nearly  useless. 
Furthermore,  treatment  by  extension  requires  confinement 
to  bed. 

Jones  of  Liverpool  thinks  that  splints  and  bandages  are 
largely  responsible  for  the  stiffness  which  so  commonly  en- 
sues upon  an  elbow  injurj^  He  advocates  treatment  by  acute 
flexion  in  all  elbow  injuries  except  fracture  of  the  olecranon. 


SPECIAL   FRACTURES. 


461 


The  ball  of  the  thumb 


In  a  fracture  of  the  humerus  he  extends,  supinates,  and  flexes 

the  foreami  to  reduce  the  displacement.     He  maintains  flexion 

by  fastening   a  bandage  around  the  wrist  and   neck.     The 

bandage   around  the   neck   passes    througfh   a   rubber   tube. 

which  sen-es  to  protect  the  neck 

should   rest   against   the   neck. 

The   bandage  is   fastened  to    a 

leather  band  around  the  wrist. 

This  position  is  maintained  from 

three  to  six  weeks. ^    The  author 

has  treated  a  number  of  cases 

by   Jones's    method,   and    now 

prefers  it  to  any  other  plan. 

The  most  con\"enient  dressing 
to  maintain  Jones's  position  was 
devised  b\-  Frazier  ;  it  is  shown 
in  Fig.  129. 

If  it  is  found  impossible  to 
reduce  the  fragments  or  to  main- 
tain reduction,  we  should  follow 
the  advice  of  John  B.  Roberts, 
make  an  incision  and  nail  the 
fragments  in  place. 

In  young  children  the  ante- 
rior angular  splint  must  not  be 
used.  It  will  become  loosened,  and  motion  will  inevitabh-  take 
place  at  the  seat  of  fracture.  Such  cases  can  be  treated 
satisfactorily  in  Jones's  position  with  Frazier's  sling,  or  we 
can  treat  them  in  extension.  Bertomier's  plan  is  ver}^  useful  in 
young  children.-  The  extremity  is  dressed  without  pressure 
in  extension  and  supination.  This  can  be  effected  by  flannel 
bandages.  In  from  four  to  eight  da}'s  a  silicate  of  sodium 
bandage  is  applied  in  order  to  prevent  pronation.  About  the 
sixteenth  day  the  bandage  is  cut  so  as  to  form  two  troughs. 
From  this  period  ever}-  third  day  the  splints  are  removed  and 
gentle  passive  motion  is  made.  The  splints  are  remov^ed 
permanenth'  at  the  end  of  four  weeks. 

If  false  ankylosis  follows  fracture,  the  adhesions  should  be 
broken  up  under  ether,  and  for  some  time  passive  motion 
should  be  made  daily  after  the  use  of  the  hot-air  apparatus. 
In  true  ankylosis  an  operation  should  be  performed  and  the 
interlocking  callus  or  the  interposed  tissue  or  fragment  re- 
moved, if  a  skiagraph  shows  that  operation  promises  success. 

'  Provincial  Medical  Journ..  Dec,  1894,  and  Jan.,  1895. 
'  Revue  de  Chir.,  vol.  viii.,  188S. 


Fig.  129. — Frazier's  modification  of 
Jones's  dressing  for  injuries  of  the  elbow- 
ioint. 


462    DISEASES  AND   INJURIES   OE  BONES  AND  JOINTS. 

If  gunstock  deformity  results  and  produces  marked  disable- 
ment, it  should  be  operated  upon.  An  osteotomy  is  per- 
formed on  the  inner  condyle.  The  arm  is  set  in  the  ex- 
tended position,  plaster  of  Paris  is  applied,  and  is  not  removed 
for  six  weeks.' 

Separation  of  the  lower  epiphysis  of  the  humerus  is  a 
not  unusual  accident.  The  inferior  extremity  of  the  humerus 
may  be  separated,  or  the  condyles  may  be  separated  from 
each  other  and  from  the  shaft  of  the  bone. 

Symptoms. — The  symptoms  are — prominence  in  front  of 
the  joint,  caused  by  the  lower  end  of  the  shaft  of  the  hume- 
rus; projection  backward  of  the  olecranon;  the  forearm  rests 
midway  between  pronation  and  supination.  Epiphyseal  sepa- 
ration may  retard  growth  and  produce  deformity. 

Treatment. — Jones's  position  or  anterior  angular  splint  as 
above  directed. 

Fractures  of  the  uhia  comprise  the  following  varieties  : 
(i)  fracture  of  the  coronoid  process;  (2)  fracture  of  the  olec- 
ranon process;  (3)  fracture  of  the  shaft;  and  (4)  fracture  of 
the  styloid  process. 

Fractures  of  the  coronoid  process  of  the  ulna  are  rarely 
observed,  and  practically  occur  only  as  a  complication  of 
backward  dislocation  of  the  ulna  or  in  association  with  other 
fractures. 

Symptoms. — When  fracture  of  the  coronoid  process  is 
associated  with  a  dislocation  crepitus  is  appreciated  on 
reduction,  and  it  is  found  that  the  deformity  of  the  disloca- 
tion promptly  returns  on  cessation  of  extension.  The  upper 
fragment  may  be  pulled  upward  by  the  brachialis  anticus 
muscle,  and  there  exists  an  inability  to  flex  the  forearm  com- 
pletely. The  position  is  one  of  extension  with  posterior  pro- 
jection of  the  olecranon.  The  broken  piece  is  felt  in  front 
of  the  joint. 

Treatment. — The  treatment  is  by  an  anterior  splint  whose 
angle  is  less  than  a  right  angle ;  the  splint  is  to  be  worn  for 
four  weeks,  and  passive  motion  is  to  be  begun  in  the  third 
week.  Jones's  position  may  be  used  in  treating  such  a  case. 
A  stiff  joint  may  follow. 

Fractures  of  the  olecranon  process  of  the  ulna  occur 
not  uncommonly  in  adults.  Hulke  states  that  such  a  fract- 
ure never  occurs  before  the  age  of  fifteen,  but  the  writer  has 
seen  in  the  Jefferson  Medical  College  Hospital  a  girl  aged 
fourteen  with  a  fractured  olecranon.  The  cause  is  direct  vio- 
lence or  muscular  action.     Only  a  small  fragment  may  be 

1  U.  G.  Davis,  Phila.  Med.  Jour.,  May  13,  1899. 


SPECIAL    FRACTURES.  463 

torn  away,  or  the  entire  olecranon  may  be  broken  off,  and 
the  break  may  be  comminuted  or  may  even  be  compound. 

Symptoms. — The  symptoms  of  fracture  of  the  olecranon 
are — swelling ;  partial  flexion  of  the  forearm ;  separation  of  the 
fragments,  the  upper  piece  being  pulled  up  from  half  an  inch 
to  two  inches  by  the  triceps ;  the  space  between  the  fragments 
is  increased  by  forearm  flexion  and  lessened  by  forearm 
extension;  there  is  inability  to  extend  the  arm.  Bulging  of 
the  triceps  above  the  fragments  and  crepitus  on  approximat- 
ing the  fragments  are  observed.  In  some  few  cases  there 
is  no  separation,  the  periosteum  being  untorn  or  the  fascial 
expansions  from  the  triceps  holding  the  fragments  in  apposi- 
tion. In  such  cases  crepitus  can  be  elicited  by  rocking  the 
upper  fragment  from  side  to  side. 

The  prognosis  is  fair,  fibrous  union  being  the  rule.  Some 
joint-stiffness  usually  occurs,  and  much  ankylosis  may  be 
unavoidable. 

Treatment. — Fracture  of  the  olecranon  is  treated  with  a 
well-padded  anterior  splint,  almost  but  not  quite  straight.  A 
perfectly  straight  splint  is  uncomfortable,  and,  by  opening 
a  retiring  angle  between  the  fragments  and  into  the  joint, 
favors  non-union  and  ankylosis.  The  splint  should  reach 
from  a  level  with  the  axillary  margin  to  below  the  fingers. 
If  the  upper  fragment  does  not  come  in  contact  with  the 
lower,  pull  it  down  by  adhesive  plaster  and  fasten  the  strips 
to  the  splint.  The  author  in  one  case  employed  a  glove  to 
which  strings  from  the  adhesive  plaster  were  attached.  After 
applying  the  splint  keep  the  patient  in  bed  for  three  weeks. 
The  danger  of  ankylosis  in  this  fracture  is  very  great,  and,  in 
case  it  occurs  in  the  position  of  extension,  an  almost  useless 
arm  results.  Follow  the  rule  of  T.  Pickering  Pick,  and  at 
the  end  of  three  weeks  anesthetize  the  patient,  press  the 
thumb  firmly  down  upon  the  top  of  the  olecranon,  put  the 
forearm  at  a  right  angle,  and  apply  an  anterior  angular  splint 
and  direct  it  to  be  worn  for  two  weeks.  When  the  anterior 
splint  has  been  applied  passive  motion  should  be  made  every 
other  day,  or  every  third  day,  and  massage  should  be  used 
at  the  same  time.  When  the  splint  is  removed  try  to  in- 
crease the  range  of  motion^  as  previously  directed.  Non- 
union  requires  wiring  of  the  fragments. 

Fractures  of  the  shaft  of  the  ulna  alone  are  usually  near 
the  middle  of  the  bone,  are  always  due  to  direct  violence,  and 
are  not  unusually  compound.  An  injury  which  breaks  the 
ulna  is  very  apt  to  break  the  radius  also. 

Symptoms. — By  running  the  finger  along  the  inner  surface 


464    DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

of  the  bone  there  are  detected  inequality  and  depression; 
crepitus  and  mobility  are  easily  developed;  there  are  pain 
and  the  evidence  of  direct  violence.  The  long  axis  of  the 
hand  is  not  on  a  line  with  the  lon<j  axis  of  the  forearm,  but  is 


Fig.  130. — Fracture  of  the  shaft  of  the  ulna  (case  in  the  Pennsylvania  Hospital ;  skiagraphed 
by  Dr.  Gaston  Torrance). 

internal  to  it.  If  deformity  exists,  it  is  due  to  the  lower  frag- 
ment passing  into  the  interosseous  space  because  of  the  action 
of  the  pronator  quadratus  muscle ;  the  upper  fragment,  acted 
on  by  the  brachialis  anticus,  passes  a  little  forward  (Fig. 
130).  The  forearm  at  and  below  the  seat  of  fracture  is  nar- 
rower and  thicker  than  normal. 


SPECIAL    FRACTURES. 


465 


Fig 


-Two  straight  splints  in  fracture  of  both 
bones  of  the  forearm. 


Treatment. — In  treating  fracture  of  the  shaft  of  the  uhia 
place  the  forearm  midway  between  pronation  and  supination, 
so  as  to  bring  the  fragments  together  and  to  obtain  the  widest 
possible  interosseous  space,  and  thus  limit  the  danger  of 
union  taking  place  between  the  radius  and  ulna.  The  posi- 
tion midway  between  pronation  and  supination  is  obtained 
by  flexing  the  forearm  to  a  right  angle  with  the  arm  and 
pointing  the  thumb  to  the  nose.  Take  two  well-padded 
straight  splints,  one  long  enough  to  reach  from  the  inner 
condyle  to  below  the  fingers,  the  other  from  the  outer 
condyle  to  below  the 
wrist;  place  a  long  pad 
of  lint  over  the  inter- 
osseous space  on  the 
flexor  side  of  the  Hmb, 
and  another  on  the  exten- 
sor side ;  apply  the  splints 
and  hang  the  arm  in  a  tri- 
angular sling  (Fig.  131). 
Passive  motion  is  to  be 
made  in  the  third  week, 
and  the  splints  are  to  be 
worn  for  four  weeks. 
Fractures  of  the  ulna  can  be  treated  very  efficiently  with 
plaster  of  Paris. 

Fractures  of  the  styloid  process  of  the  ulna  are  due  to 
direct  force.     The  displacement  is  obvious. 

Treatment. — In  treating  fracture  of  the  styloid  process  push 
the  fragment  back  into  place  and  use  a  Bond  splint  with  a 
compress  for  four  weeks,  or  a  plaster-of- Paris  dressing. 

Fractures  of  the  radius  include  the  following  varieties  : 
{a)  fractures  of  its  head;  {b)  fractures  of  its  neck;  {c)  fract- 
ures of  its  shaft ;  and  {d)    fractures    of  its  lower  extremity. 

Fracture  of  the  head  of  the  radius  very  rarely  occurs 
alone,  but  it  may  complicate  backward  dislocation  of  the 
radius. 

Symptoms. — The  symptoms  of  fracture  of  the  head  of  the 
radius  are  crepitus  on  passive  pronation  and  supination,  and 
loss  of  voluntary  pronation  and  supination. 

Treatment. — The  treatment  of  a  fracture  of  the  head  of  the 
radius  is  the  same  as  for  a  fracture  in  or  near  the  elbow- 
joint,  namely,  an  anterior  angular  splint  for  four  or  five 
weeks,  or  placing  the  extremity  in  Jones's  position. 

Fracture  of  the  neck  of  the  radius  very  rarely  occurs 
alone. 

30 


466   DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS. 

Sy»iptoi)is. — In  this  fracture  the  forearm  is  pronated  and 
the  patient  is  found  to  have  lost  the  power  of  voluntary  pro- 
nation and  supination.  Under  forced  pronation  and  supina- 
tion it  will  be  noted  that  the  head  of  the  radius  does  not 
move  and  crepitus  is  felt.  The  lower  fragment,  being  pulled 
upward  and  forward  by  the  biceps,  can  be  felt  in  front  of  the 
elbow-joint. 

Treatment. — The  treatment  for  fracture  of  the  neck  of  the 
radius  is  the  same  as  for  fracture  of  the  elbow-joint — namely, 
an  anterior  angular  splint  or  Jones's  position. 

Fracture  of  the  shaft  of  the  radius  is  far  commoner 
than  fracture  of  the  shaft  of  the  ulna.  It  may  occur  above 
or  below  the  insertion  of  the  pronator  radii  teres  muscle.  It 
may  arise  from  either  direct  or  indirect  force.  Fracture  of 
the  shaft  of  the  ulna  may  coexist  as  a  result  of  the  same 
accident. 

Fracture  of  the  Radius  above  the  Insertion  of  the 
Pronator  Radii  Teres  Muscle. — Symptoms. — The  upper 
fragment  is  drawn  forward  by  the  biceps  and  is  fully  supi- 
nated  by  the  supinator  brevis.  The  lower  fragment  is  fully 
pronated  by  the  pronator  quadratus  and  pronator  radii  teres, 
and  its  upper  end  is  pulled  into  the  interosseous  space. 
There  are  crepitus,  mobility,  pain,  narrowing  and  thickening 
of  the  forearm  below  the  seat  of  fracture,  and  loss  of  the 
power  of  pronation  and  supination.  The  head  of  the  bone 
is  motionless  during  passive  pronation  and  supination.  The 
hand  is  prone. 

Treatment. — In  treating  this  fracture  do  not  put  the 
forearm  midway  between  pronation  and  supination,  as  this 
position  will  not  bring  the  fragments  into  contact,  the  upper 
fragment  remaining  flexed  and  supinated.  To  bring  the 
lower  fragment  in  contact  with  the  upper,  flex  and  fully 
supinate  the  forearm.  Apply  an  anterior  angular  splint  to  the 
extremity  for  four  weeks,  and  make  passive  motion  in  the 
third  week. 

Fracture  of  the  Radius  below  the  Insertion  of  the 
Pronator  Radii  Teres  Muscle, — In  this  variety  of  fracture 
the  upper  fragment  is  acted  on  by  the  biceps,  the  supinator 
brevis,  and  the  pronator  radii  teres,  and  it  remains  about 
midway  between  pronation  and  supination,  passing  forward 
and  also  into  the  interosseous  space.  The  lower  fragment 
is  acted  on  by  the  supinator  longus  and  the  pronator  quad- 
ratus, the  latter  being  the  more  powerful  of  the  two,  and  the 
lower  fragment  is  moderately  pronated,  its  upper  extremity 
being  drawn  into  the  interosseous  space.     Other  symptoms 


SPECIAL    FRACTURES.  467 

are  identical  with  those  of  fracture  above  the  insertion  of  the 
pronator  radii  teres. 

Treatment. — In  treating  fracture  below  the  pronator  radii 
teres  the  forearm  is  flexed  and  is  placed  midwa}'  between 
pronation  and  supination ;  tw^o  interosseous  pads  and  two 
straight  splints  are  applied  as  for  fracture  of  the  ulna  (Fig. 
131).  The  splints  are  worn  for  four  weeks,  and  passive 
motion  is  made  in  the  third  week.  Plaster  of  Paris  is  a  most 
satisfactory  dressing. 

Fracture  of  the  shafts  of  both  bones  of  the  forearm  is 
not  frequently  seen.     It  is  caused  by  direct  or  indirect  force. 

SyniptODis. — In  fracture  of  both  bones  of  the  forearm  the 
hand  is  pronated  and  the  lower  two  fragments  come  together 
and  are  drawn  upward  and  backward  or  upward  and  forward 
by  the  combined  force  of  flexor  and  extensor  muscles,  short- 
ening being  manifest  and  the  projection  of  the  lower  frag- 
ments being  detected  on  either  the  dorsal  or  the  flexor  sur- 
face of  the  forearm.  The  upper  fragment  of  the  ulna  is 
somewhat  flexed  by  the  brachialis  anticus  ;  the  upper  frag- 
ment of  the  radius  is  flexed  by  the  biceps  and  is  pronated 
and  drawn  toward  the  ulna  by  the  pronator  radii  teres.  The 
forearm  is  narrower  than  it  should  be  (the  ends  of  the  frag- 
ments having  passed  into  the  interosseous  space)  and  is 
thicker  than  normal  from  front  to  back  (the  contents  of  the 
interosseous  space  having  been  forced  out).  Crepitus, 
mobilit}-,  pain,  and  inequality  exist,  the  power  of  rotation  is 
lost,  and  on  passive  rotation  the  head  of  the  radius  does  not 
move.     The  forearm  is  prone  and  semiflexed. 

Treatment. — The  treatment  consists  in  the  application  of 
two  straight  splints  and  two  interosseous  pads,  the  forearm 
being  flexed  to  a  right  angle  and  placed  midway  between 
pronation  and  supination  (Fig.  135).  The  splints  are  worn 
for  four  weeks,  and  passive  motion  is  made  in  the  third  week. 
Instead  of  these  splints,  a  plaster-of-Paris  dressing  can  be  used. 

Fractures  of  the  Lower  Extremity  of  the  Radius. —  Col- 
les's  fracture  is  a  transverse  or  nearl}-  transverse  fracture  of 
the  lower  end  of  the  radius,  between  the  limits  of  one-quarter 
of  an  inch  and  one  and  a  half  inches  above  the  wrist-joint, 
the  lower  fragment  sometimes  mounting  upon  the  dorsum  of 
the  upper  fragment.  An  oblique  fracture  beginning  within  half 
an  inch  of  the  joint  and  passing  into  the  joint  is  known  as 
Barton's  fracture.  Colles's  fracture  was  first  recognized 
as  a  fracture  by  Colles,  of  Dublin,  in  18 14.  Before 
this  time  the  injury  was  called  backward  dislocation  of 
the  wrist.     It  is  a  very  common  injury,  is  met    with  most 


468   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 


Fig.  132. — Effect  upon  the  lower  end  of 
the  radius  of  the  cross-breaking  strain  pro- 
duced by  extreme  backward  flexion  of  the 
hand  (Pilcher). 


frequently  in  those  beyond  the  age  of  forty,  and  oftener  in 
women  than  in  men.  It  is  due  to  transmitted  force  (a 
fall    upon    the    palm  of    the  pronated   hand).     Some  think 

that  the  force  is  received  by 
the  ball  of  the  thumb  and 
passes  to  the  carpal  bones  and 
the  edge  of  the  radius ;  a 
fracture  begins  posteriorly 
rather  than  anteriorly,  the 
force  driving  the  fragment 
upon  the  dorsal  surface  of  the 
radius,  the  carpus  and  lower 
fragment  movdng  upward  and 
outward.  It  is  much  more 
likely  that  this  fracture  is  due 
to  cross-strain  on  the  bone. 
There  is  sudden  traction  upon 
the  anterior  ligaments,  which 
drag  upon  the  bone  and 
break  it  at  a  point  where 
the  cancellous  end  of  the  ra- 
dius joins  the  compact  shaft 
(Fig.  132).  The  fragments  are  not  unusually  impacted.  In 
the  author's  experience  dislocation  of  the  lower  end  of  the 
ulna  is  a  not  unusual  complication,  which  arises  from  a  fract- 
ure of  the  ulnar  styloid  or  tearing  off  of  the  internal  lateral 
ligament  of  the  wrist. 

Symptoms. — In  Colles's  fracture  the  hand  is  abducted 
(drawn  to  the  radial  side  of  the  forearm)  and  pronated,  the 
head  of  the  ulna  is  prominent,  the  styloid  process  of  the 
radius  is  raised,  and  the  lower  fragment  may  mount  on  the 
back  of  the  lower  end  of  the  upper  fragment,  causing  a 
dorsal  projection,  termed  by  Liston  the  "  silver-fork  de- 
formity." The  lower  end  of  the  upper  fragment  can  be  felt 
beneath  the  flexor  tendons  above  the  wrist.  The  position 
in  deformity  is  produced  by  the  force.  Some  consider  it  is 
maintained  by  the  action  of  the  supinator  longus  and  the 
flexor  and  extensor  muscles,  but  particularly  by  the  exten- 
sors of  the  thumb.  Pilcher  has  demonstrated  the  fact  that 
in  this  fracture  a  portion  of  the  dorsal  periosteum  is  untorn, 
and  this  untorn  portion  acts  as  a  binding  band  to  hold  the 
fragments  in  deformity.  Pronation  and  supination  are  lost. 
In  this  fracture  the  hand  can  be  greatly  hyperextended 
(Maisonneuve's  symptom).  Crepitus,  which  is  best  obtained 
by   alternate    hyperextension    and    flexion,   can    be    secured 


SPECIAL   FRACTURES. 


469 


unless  swelling  is   great   or  impaction   exists.     Crepitus  on 
side  movements  is  rarely  obtainable.    Impaction  may  greatly 


Figs.  133,    134. — Deformity  at  the  wrist  consequent    upon  displacement  backward   of  the 
lower  fragment  of  the  radius  after  fracture  at  its  lower  extremity  (Levis). 

modify  the  deformit}',  though  displacement  generally  exists 
to  some  extent,  and  the  fragments  do  not  ride  easily  on  each 


Fig.  135. — CoUes's  fracture  of  the  radius  (Pennsylvania  Hospital  case;  skiagraphed  by  Dr. 
Gaston  Torrance). 

other.     The  styloid  process  of  the  ulna  may  be  broken,  or 
the  inferior  radio-ulnar  articulation  may  be  separated.     This 


4/0   DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS. 

latter  complication  allows  the  lower  fragment  to  roll  freely 
upon  the  upper,  and  the  characteristic  silver-fork  deformity- 
does  not  appear.  If  the  styloid  process  of  the  ulna  is  broken, 
pressure  over  it  causes  great  pain.  If  a  person  in  falling 
strikes  the  back  of  the  hand  and  a  fracture  of  the  radius 
occurs,  the  lower  fragment  is  driven  upon  the  front  surface 
of  the  upper  fragment  and  is  felt  under  the  flexor  tendons  at 
the  wrist.  An  elaborate  study  of  fracture  of  the  radius  with 
forward  displacement  of  the  lower  fragment  has  been  pub- 
lished by  John  B.  Roberts.^ 

Treatment. — In   treating   Colles's   fracture   reduce  the  de- 
formity by  hyperextension  to  unlock  the  fragments  and  relax 


Fig.  136.— Levis's  radius-splints,  right  and  left,  for  fracture  of  the  lower  end  of  the  radius. 

the  dorsal  periosteum,  and  follow  by  longitudinal  traction  to 
separate  the  fragments,  and  forced  flexion  to  force  them 
into  position.  This  formula  was  introduced  many  years  ago 
by  the  late  R.  J.  Levis.  It  is  of  the  first  importance  to 
thoroughly  reduce  this  fracture,  and  very  often  it  is  not 
thoroughly  reduced.  Imperfect  reduction  means  permanent 
deformity,  stiffness  of  the  tendons  and  wrist,  and  possibly  an 
almost  useless  hand.  The  extremity  can  be  placed  upon  a 
Levis  splint  (Fig.  136),  the  position  maintaining  reduction  and 
the  tense  extensor  tendons  giving  dorsal  support.  Some 
surgeons  use  Gordon's  pistol-shaped  splint.  The  favorite 
splint  in  Philadelphia  practice  in  the  past  has  been  Bond's 
(Fig-  ^'h7)-     It  places  the  hand  in  a  natural  position  of  rest 

^  Avi.  Jour.  Med.  Sci.,  Jan.,  1897. 


SPECIAL   FRACTURES. 


471 


(semiflexion  of  the  fingers,  semi-extension  of  the  wrist,  and 
deviation  of  the  hand  toward  the  ulna).    Two  pads  are  used  : 
a  dorsal  pad  which  oxerlies  the  lower  fragment,  and  a  pad 
for  the  flexor  surface  which  over- 
lies the  lower  end  of  the  upper 
fragment.     A    bandage    is    ap- 
plied, the  thumb  and  fingers  be- 
ing left  free  (Fig.  84;  PI.  6,  Fig. 
7).     Passive    motion    is    begun 
upon  the  fingers  in  three  or  four 
davs,  and  upon  the  wrist  during 
the  second  week.     The  splint  is 
removed  in  three  weeks,   and  a 
bandage  is  worn  for  a  week  or 
two  rnore  because  of  the  swell- 
ing. In  applying  the  Bond  splint, 
do  not  pull  the  hand  too  much 
up  on  the  block,  or  the  fracture  iracture. 

will  unite  with  a  projection  upon 

the  flexor  surface  of  the  extremit}^  and  the  tendons  of  the  wn^t 
will  be  apt  to  be  caught  in  the  callus.  Jhe  niost  satisiacto^- 
dressing  is  the  straight  dorsal  splint  advised  by  Roberts^  U 
prevents  the  recurrence  of  deformity'  (Tig.  1 38)  and  is  mechani- 


Coiles's 


Fic-   x.S.-DLagram   showing  the   arrangement,  of  ^°-P--,^„^,'Va& ^'  ^'^"^'''^   '" 
retain  fragments  in  proper  posiuon  after  reduction  (Pilcher). 

callv  the  proper  mode  of  treatment.  It  should  be  worn  for 
three  weeks.  Undoubted!}^  more  or  less  stiffness  often 
follows  CoUes's  fracture,  and  some  ver)'  able  surgeons  have 
been  so  impressed  with  the  frequency  of  its  occurrence  that 
thev  have  dispensed  with  the  use  of  a  splint,  bir  Astley 
Cooper  long  ago  spoke  of  placing  the  arm  in  a  sling  as 
proper  treatment  for  fracture  of  the  radius.  ^loore  of 
Rochester,  applied  a  cvlindrical  compress  o^•er  the  ulna,  held 
in  place  for  six  hours  with  adhesive  plaster  then  cut  the 
plaster  placed  the  forearm  in  a  sling,  and  let  the  hand  hang 


472   DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS. 

over  the  edge  of  the  sling.  Pilcher  applies  a  band  of  adhe- 
sive plaster  around  the  wrist  and  supports  the  wrist  in  a 
sling.  Storp  says  that  dispensary  patients  are  apt  to  dis- 
arrange this  dressing.^  He  wraps  a  piece  of  rubber  plaster 
four  inches  wide  around  the  wrist,  and  places  a  second  piece 
around  the  first  so  arranged  as  to  form  a  fold  over  the 
radius ;  an  opening  is  made  through  the  fold  for  the  passage 
of  a  sling.  In  ten  days  the  plaster  is  removed  and  the  fore- 
arm is  carried  in  a  sling.  If  a  stiff  joint  and  limited  tendon- 
motion  eventuate  from  the  fracture,  use  massage,  frictions, 
sorbefacient  ointments,  tincture  of  iodin,  electricity,  hot  and 
cold  douches,  and  the  hot-air  apparatus,  or  give  ether  and 
forcibly  break  up  adhesions.  If  reduction  was  not  thoroughly 
effected  and  too  great  a  length  of  time  has  not  elapsed,  and 
the  hand  is  helpless  and  painful,  the  bone  should  be  refract- 
ured.  In  a  young  or  middle-aged  person,  in  whom  a  useless 
hand  has  followed  an  ill-reduced  fracture,  osteotomy  is  justi- 
fiable. 

Fracture  of  both  the  Radius  and  Ulna  near  the  Wrist. 
— Colles's  fracture  may  be  complicated  by  a  fracture  of  the 
ulna  other  than  of  its  styloid  process. 

Symptoms. — In  fracture  of  the  radius  and  ulna  near  the 
wrist  the  lower  ends  of  the  upper  fragments  come  together, 
the  upper  fragment  of  the  radius  is  pronated,  and  the  lower 
fragment  of  the  radius  is  drawn  up.  Pain,  crepitus,  mobility, 
shortening,  and  loss  of  function  exist. 

Treatment. — Fracture  of  the  radius  and  ulna  near  the  wrist 
should  be  treated  with  the  straight  dorsal  splint,  as  in 
Colles's  fracture. 

Separation  of  the  LoTver  Radial  Epiphysis. — This  acci- 
dent occurs  in  children  from  falHng  upon  the  palm  of  the 
hand.     It  never  happens  after  the  twentieth  year. 

Symptoms. — In  separation  of  the  lower  radial  epiphysis  the 
lower  fragment  mounts  upon  the  upper  and  produces  a 
dorsal  projection  like  Colles's  fracture,  but  the  hand  does  not 
deviate  to  the  radial  side.  The  deformity  resembles  that  of 
a  backward  carpal  dislocation,  but  is  differentiated  from  dis- 
location by  the  unaltered  relation  in  the  fracture  between  the 
styloid  processes  and  the  carpal  bones. 

Treatment. — The  treatment  in  separation  of  the  lower 
radial  epiphysis  is  the  same  as  for  Colles's  fracture. 

Fractures  of  the  carpus  are  not  frequent,  and  they  are 
usually  compound.     The  cause  is  violent  direct  force. 

Symptoms. — Fractures  of  the  carpus  are  indicated  by  pain, 

^  Arch.  f.  klin.  Chii.,  liii. 


SPECL4L    FRACTURES.  473 

svvellint:^,  evidences  of  direct  force,  sometimes  crepitus,  loss 
of  power  in  the  hand,  and  a  very  httle  displacement. 

Treatment. — Many  compound  comminuted  fractures  of  the 
carpus  require  amputation.  In  an  ordinary  compound  fract- 
ure, asepticize,  drain,  dress  with  antiseptic  gauze  and  a  plas- 
ter-of-Paris  bandage,  cutting  trap-doors  in  the  plaster  over 
the  ends  of  the  drainage-tube.  In  a  simple  fracture  dress  the 
hand  upon  a  well-padded  straight  palmar  splint  (PI.  5,  Fig. 
10)  reaching  from  beyond  the  fingers  to  the  middle  of  the 
forearm,  and  place  the  hand  and  forearm  in  a  sling.  The 
splint  is  worn  for  four  weeks,  and  passive  motion  of  the 
wrist  is  begun  in  the  second    week. 

Fractures  of  the  Metacarpal  Bones. — Fracture  of  the  meta- 
carpus is  very  common.  One  or  more  bones  may  be  broken. 
The  first  metacarpal  bone  is  oftenest  broken ;  the  third  is 
rarely  broken  (Hulke).     The  cause  is  direct  or  indirect  force. 

Symptoms. — The  signs  of  a  metacarpal  fracture  are — dorsal 
projection  of  the  upper  end  of  the  lower  fragment  or  the 
lower  end  of  the  upper  fragment ;  pain  ;  crepitus  ;  and  often 
evidences  of  direct  violence. 

Treatment. — To  treat  a  fracture  of  a  metacarpal  bone  re- 
duce by  extension ;  place  a  large  ball  of  oakum,  cotton,  or 
lint  in  the  palm  to  maintain  the  natural  rotundity,  and  apply 
a  straight  palmar  splint  like  that  used  for  fracture  of  the  car- 
pus (PI.  6,  Fig.  10).  It  may  be  necessary  to  apply  a  compress 
over  the  dorsal  projection.  The  duration  of  treatment  is  three 
weeks,  and  passive  motion  is  begun  after  two  weeks.  A  plas- 
ter-of-Paris  dressing  is  often  used. 

Fractures  of  the  Phalanges. — The  phalanges  are  often 
broken.  The  fracture  may  be  compound.  The  cause  usually 
is  direct  force. 

Symptoms. — Fracture  of  the  phalanges  is  indicated  by 
pain,  bruising,  crepitus,  and  mobility,  with  veiy  little  or  no 
displacement. 

Treatment. — If  the  middle  or  distal  phalanx  is  broken, 
mould  on  a  trough-like  splint  of  gutta-percha  or  of  paste- 
board, which  splint  need  not  reach  into  the  palm.  If  the 
proximal  phalanx  is  broken,  carry  the  splint  into  the  palm  of 
the  hand.  Make  the  splint  of  gutta-percha,  pasteboard,  wood, 
or  leather.  The  splint  is  worn  three  weeks.  A  sling  must 
be  worn,  otherwise  the  finger  will  constantly  be  knocked  and 
hurt.  Some  cases  require  a  dorsal  as  well  as  a  palmar  splint. 
These  cases  are  dressed  most  satisfactorily  with  a  silicate- 
of-sodium  or  plaster-of-Paris  bandage. 

Fracture  of  the  femur  is  a  very  common  injury.     The 


474   DISEASES  AND   IXJ CRIES    OF  BONES  AND  JOINTS. 

divisions  of  the  Temur  are  ( I )  the  upper  extremity;  (2)  the 
shaft;  and  (3)  the  lower  extremit)-. 

I.  Fractures  of  the  upper  extremity  of  the  femur  are 
divided  into  {a)  intracapsular;  (<$ij  extracapsular ;  {c)  of  the 
great  trochanter ;  and  {d)  epiphyseal  separation  (either  of 
the  great  trochanter  or  the  head). 

Intracapsular  Fracture  of  the  Femiur. — This  fracture  of 
the   neck   is   transverse   or  only  slightly  oblique  (Fig.  139), 


Fig.  139. — Intracapsular  fracture  of  the  hip  (Pennsylvania  Hospital  case;  skiagraphed  by 
Dr.  Gaston  Torrance). 

and  is  not  unusually  impacted.  The  ca2isc  is  often  slight  in- 
direct force,  of  the  nature  of  a  twist,  acting  upon  a  person 
of  advanced  years  (more  often  a  woman  than  a  man),  but  not 
unusually  a  fall  upon  the  great  trochanter  is  the  cause.  A 
fall  upon  the  knees,  a  trip,  or  an  attempt  to  prevent  a  fall  may 
produce  this  fracture.  It  often  happens  that  the  fall  is  due 
to  the  fracture  rather  than   that  the  fracture  arises  from  the 


SPECIAL    FRACTURES.  475 

fall.  Intracapsular  fracture  is  never  caused  by  direct  force 
unless  it  is  due  to  gunshot  violence.  The  aged  are  more 
liable  to  intracapsular  fracture  than  the  young  or  the 
middle-aged,  because,  first,  the  angle  which  the  neck  forms 
with  the  axis  of  the  femur  becomes  less  obtuse  with  advanc- 
ing years,  and  may  even  form  a  right  angle ;  this  change  is 
more  pronounced  in  women  than  in  men;  secondly,  ■  the 
compact  tissue  becomes  thinned  by  absorption,  the  cancelli 
diminish,  the  spaces  between  them  enlarge,  the  bony  por- 
tions of  the  cancellous  structure  are  thinned  or  destroyed, 
and  the  cancellous  structure  becomes  fatty  and  degenerated. 
Sutton  has  shown  that  in  very  rare  cases  this  fracture  may 
occur  in  the  young,  even  before  the  union  of  the  epiph}^ses. 
Stokes  follows  Gordon  of  Belfast  in  classifying  fractures  of 
the  femoral  neck.  He  divides  them  into  intracapsular  and 
extracapsular,  and  subdivides  intracapsular  fractures  into 
fracture  with  penetration  of  the  cervix  into  the  head;  fract- 
ure with  reciprocal  penetration;  intraperiosteal  fracture  at 
the  junction  of  the  cervix  and  head;  intraperiosteal  fracture 
of  the  center  of  the  cervix;  extraperiosteal  fracture,  with 
laceration  of  the  cervical  ligaments.  The  last-named  fract- 
ure is  the  most  common.  The  first  four  forms  may  unite  by 
bone,  the  fifth  form  will  not  because  of  non-apposition,  lack 
of  nutrition,  effusion  of  blood,  synovitis,  or  interstitial  absorp- 
tion.^ Stokes  claims  that  we  may  have  penetration,  but  not 
impaction. 

Symptoms. — In  intracapsular  fracture  there  is  usually 
shortening  to  the  extent  of  from  half  an  inch  to  an  inch; 
HutTnsome  cases  no  shortening  can  be  detected.  Shorten- 
ing of  a  quarter  of  an  inch  does  not  count  in  making 
a  diagnosis,  for  one  limb  is  often  naturally  a  little  shorter 
than  the  othef.  If  the  reflected  portion  of  the  capsule  is 
not  torn,  the  shortening  is  trivial  in  amount  or  is  entirely 
absent.  In  some  cases  shortening  gradually  or  suddenly 
increases  some  little  time  after  the  accident.  This  is  due  to 
separation  of  a  penetration,  tearing  of  the  previously  unlac- 
erated  fibrous  synovial  reflection,  or  restoration  of  muscular 
strength  after  a  paresis.  A  gradually  increasing  shortening 
arises  from  absorption  of  the  head  of  the  bone.  Shortening 
is  due  chiefly  to  pulling  upon  the  lower  fragment  by  the 
hamstrings,  the  glutei,  and  the  rectus. 

Pain  is  usually  present  anteriorly,  posteriorly,  and  to  the 
side.  The  area  of  pain  is  localized,  and  motion  or  pressure 
greatly  increases  the  suffering. 

1  Stokes,  in  Brit.  Med.  Jour.,  Oct.  I2,  1895. 


476   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

Evcrsion  exists,  spoken  of  as  "  helpless  eversion,"  though 
in  a  very  {qw  instances  the  patient  can  still  invert  the  leg. 
This  eversion  is  due  to  the  force  of  gravity,  the  limb  rolling 
outward  because  the  line  of  gravity  has  moved  externally. 
That  eversion  is  not  due  to  the  action  of  the  external  rotator 
muscles,  as  was  taught  by  Astley  Cooper,  is  proved  by  the 
fact  that  when  a  fracture  happens  in  the  shaft  below  the 
insertion  of  these  muscles  the  lower  fragment  still  rotates 
outward.  This  is  further  demonstrated  by  the  considera- 
tions that  the  internal  rotators  are  more  powerful  than  the 
external,  that  some  patients  can  still  invert  the  limb  after  a 
fracture,  and  that  eversion  persists  during  anesthesia.^  In 
some  unusual  cases  inversion  attends  the  fracture.  Inver- 
sion, if  it  exists,  is  due  to  the  fact  that  the  limb  was  adducted 
and  inverted  at  the  time  of  the  accident,  and  after  the  acci- 
dent it  remains  in  this  position  (Stokes).  Besides  shortening 
and  eversion,  the  leg  is  somewhat  flexed  on  the  thigh  and 
the  thigh  on  the  pelvis,  the  extremity  when  rolled  out  resting 
upon  its  outer  surface.     Abduction  is  commonly  present. 

Loss  of  power  is  a  prominent  symptom :  the  limb  can 
rarely  be  raised  or  inverted ;  although  in  rare  cases,  when 
the  fibrous  synovial  envelope  is  untorn,the  patient  may  stand 
or  even  take  steps.  Pain  is  not  commonly  severe  except  upon 
motion,  when  it  may  be  localized  in  the  joint.  In  some  cases 
the  pain  is  violent.  Crepitus  often  cannot  be  found,  either 
because  the  fragments  cannot  be  approximated,  because  pene- 
tration exists,  or  because  they  are  greatly  softened  by  fatty 
change.  To  obtain  crepitus  the  front  of  the  joint  must  be 
examined  while  the  limb  is  extended  and  rotated  inward. 
But  why  try  to  obtain  crepitus  ?  The  diagnosis  is  readily 
made  without  it ;  in  many  cases  it  cannot  be  detected,  and 
the  endeavor  to  obtain  it  inflicts  pain  and  may  produce  dam- 
age. These  fractures  offer  a  not  very  flattering  chance  of 
repair,  and  efforts  to  find  crepitus  may  produce  serious  dam- 
age. 

Altei^ed  Arc  of  Rotation  of  the  Great  Trocliantcr  (Desault's 
sign). — The  pivot  on  which  the  great  trochanter  revolves  is 
no  longer  the  acetabulum,  and  the  great  trochanter  no  longer 
describes  the  segment  of  a  circle,  but  rotates  only  as  the 
apex  of  the  femur,  which  rotates  around  its  own  axis.  It  is 
needless  to  try  to  obtain  this  sign  ;  to  do  so  inflicts  violence 
on  the  parts. 

Relaxation  of  the  fascia  lata  (Allis's  sign)  simply  means 
shortening.     The  fascia  lata  is  attached  to  the  ilium  and  the 

1  Edmund  Owen  :  A   Manual  of  Anatomy. 


SPECIAL    FRACTURES.  477 

tibia  (iliotibial  band),  and  when  shortening  brings  the  tibia 
nearer  to  the  ihum  this  band  relaxes  and  permits  one  to  push 
more  deeply  inward  on  the  injured  side,  between  the  great 
trochanter  and  the  iliac  crest,  and  near  the  knee  above  the 
outer  condyle,  than  on  the  sound  side.  In  this  examination 
each  hmb  should  be  adducted.  AlHs  has  pointed  out 
another  sign  :  when  the  patient  is  recumbent  the  sound  thigh 
cannot  be  raised  to  the  perpendicular  without  flexing  the 
leg  :  the  injured  thigh  can  be.  Lagoria's  sign  is  a  relaxation 
of  the  extensor  muscles. 

Ascent  of  the  Great  TrocJianter  above  Nelatotis  Line. — 
This  line  is  taken  from  the  anterior  superior  iliac  spine  to  the 
most  prominent  part  of  the  ischial  tuberosity  (Fig.  140).  In 
health  the  great  trochanter  is  below,  and  in  intracapsular 
fracture  it  is  above,  this  line. 

Relation  of  the  Trochanter  to  Bryant's  Triangle  (Fig.  1401 — 
Place  the  patient  recumbent,  carr}^  a  line  around  the  body  on 
a  level  with  the  anterior  superior  iliac  spines,  draw  a  line 
from  the  anterior  iliac  spine  on  each  side  to  the  summit  of 
the  corresponding  great  trochanter,  and  measure  the  base 
of  the  triangle  from  the  great  trochanter  to  the  perpen- 
dicular hne  to  determine  the  amount  of  ascent.  The 
difference  in  measurement  between  the  two  sides  shows  the 
amount  of  ascent  of  the  trochanter;  that  is,  shows  the  extent 
of  shortening. 

JMorns's  ijieasnrement  shows  the  extent  of  inward  displace- 
ment.    Measure  from  the  median  line 
of  the  body  to  a  perpendicular  line  a 

drawn    through    the   trochanter    on  /^^'^^ 

each  side  of  the  body.  &^lYJr''~  'f-'^^^^ 

Diagnosis. — Intracapsular  fracture     u^^^fev"*'-^! — '^^^^~— 
without  separation  of  the  fragments      ^^^k^    r"*^     '^^ 
may  be  mistaken   for  a  mere  contu-  ^^"ii^^^^ 

sion,  and  the  diagnosis  may  continue  ^^^^^sf 

obscure  unless  the  fragments  sepa-       fig.  140.— a  c  d,  Bryant's  iUo- 

T  r   r  j^-  ■  i       •  femoral  triangle ;  A   B,  Nelaton's 

rate.     Loss  01  1  unction  m  contusion     line(Owen). 
is    rarely    complete    or    prolon'ged 

although  occasionally  the  head  of  the  bone  is  absorbed. 
Early  after  a  contusion,  and  usually  throughout  the  case, 
there  is  no  alteration  between  the  relation  of  the  spine  of  the 
ilium  and  the  trochanter,  and  no  shortening.  Some  little 
time  after  a  se\'ere  contusion  the  head  of  the  bone  may  be 
absorbed.  Contusion  of  a  rheumatic  joint  leads  to  much 
difficulty  in  diagnosis.  Intracapsular  fracture  may  be  con- 
fused with  extracapsular  fracture  or  with  a  dislocation  of  the 


478   DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS. 

hip-joint.  Extracapsular  fracture,  which  is  common  in 
advanced  Hfe,  but  is  met  with  in  middle  life  or  even  occasion- 
ally in  the  young,  results  usually  from  great  violence  over 
the  great  trochanter;  if  non-impacted,  there  are  noted 
shortening  of  from  one  and  a  half  to  three  inches,  crepitus 
over  the  great  trochanter,  and  usually,  but  not  invariably, 
eversion ;  if  impacted,  there  is  less  eversion,  crepitus  is 
almost  or  entirely  absent,  and  the  shortening  is  limited  to 
about  an  inch.  Great  tenderness  exists  over  the  great 
trochanter  in  both  impacted  and  non-impacted  fractures. 
The  extensor  muscles  are  relaxed.  In  dislocation  on  the 
dorsum  of  the  ilium  the  patient  is  usually  a  strong  young 
adult.  There  is  a  history  of  forcible  internal  rotation.  There 
are  inversion  (the  ball  of  the  great  toe  resting  on  the  instep 
of  the  sound  foot),  rigidity,  ascent  of  the  bone  above  Nek- 
ton's line,  and  shortening  of  from  one  to  three  inches.  The 
head  of  the  bone  is  felt  on  the  dorsum  of  the  ilium,  and  the 
trochanter  mounts  up  toward  the  spine  of  the  ilium,  and 
pressure  upon  it  causes  no  pain.  In  dislocation  into  the 
thyroid  notch  there  is  possibly  eversion,  but  it  is  linked 
with  lengthening. 

In  fracture  of  the  brim  of  the  acetabiihun  there  is  shorten- 
ing, which  occurs  on  the  rem.oval  of  extension,  inversion, 
retained  power  of  everting  the  limb,  abduction,  retained 
power  of  adduction,  flexion  of  the  knee,  and  the  head  of  bone 
is  drawn  upward  and  backward  with  the  acetabular  fragment 
(Stokes).  Crepitus  is  most  distinctly  appreciated  by  a  hand 
resting  on  the  ilium.  In  fracture  of  the  fundus  of  the 
acetabulum  there  is  shortening,  and  the  head  of  the  bone 
enters  the  pelvis  (Stokes). 

Prognosis. — The  prognosis  is  not  very  favorable.  Old 
people  not  unusually  die.  Many  surgeons  have  maintained 
that  bony  union  never  occurs,  but  it  certainly  does  sometimes 
take  place.  Stokes  holds  that  bony  union  is  possible  in 
fractures  with  penetration,  and  even  in  fractures  without 
penetration  when  the  fracture  is  within  the  periosteum.^ 
Non-union  is  not  unusual.  Permanent  shortening  to  some 
degree  is  inevitable,  and  the  function  of  the  joint  is  sure  to 
be  more  or  less  impaired.  It  will  be  found  necessary  in  many 
cases  for  the  patient  to  always  employ  support  in  walking. 

Treatment. — In  treating  a  very  feeble  person  for  intracap- 
sular fracture  make  no  attempt  to  obtain  union.  Keep  the 
patient  in  bed  for  two  weeks,  give  lateral  support  by  sand- 
bags, tie  around  the  ankle  a  fillet,  attach  a  weight  of  a  few 

1  See  the  masterly  paper  of   Stokes,  before  quoted. 


SPECIAL    FRACTURES  479 

pounds  to  the  fillet,  and  hang  the  weight  over  the  foot-board 
of  the  bed.  When  pain  and  tenderness  abate,  order  the 
patient  to  get  into  a  reclining-chair,  and  permit  him  ven,-  soon 
to  get  about  on  crutches.  If  h\-postatic  congestion  of  the 
lung  sets  in,  if  bed-sores  appear,  if  the  appetite  and  diges- 
tion utterly  fail,  or  if  diarrhea  persists,  abandon  attempts  at 
cure  in  any  case,  and  get  the  patient  up  and  take  him  into  the 
sunshine  and  fresh  air,  simply  immobilizing  the  fracture  as 
thoroughly  as  possible  by  means  of  pasteboard  splints.  In 
the  vast  majority  of  cases,  no  matter  how  old  the  patients, 
undertake  treatment.  We  may  be  forced  to  abandon  it,  but 
should  at  least  attempt  to  obtain  a  cure.  If  it  is  determined 
to  treat  the  case,  combine  extension  with  lateral  support  by 
means  of  sand-bags  and  the  extension  apparatus  originally 
devised  by  Gurdon  Buck.  The  extension  should  be  gentle, 
never  forcible.  It  is  not  wise  to  pull  apart  a  penetration  in 
an  old  person,  but  it  should  alwa\-s  be  done  in  a  young  or 
middle-aged  person.  Place  the  subject  on  a  firm  mattress, 
and  if  the  patient  be  a  man,  shave  the  leg.  Cut  a  foot-piece 
out  of  a  cigar-box,  perforate  it  for  a  cord,  wrap  it  with  ad- 
hesive plaster  as  shown  in  Plate  6,  Figs.  15  and  16,  run  the 
weight-cord  through  the  opening  in  the  wood,  and  fasten  a 
piece  of  adhesive  plaster  on  each  side  of  the  leg,  from  just 
below  the  seat  of  fracture  to  above  the  malleolus  (PI.  6.  Fig. 
14).  The  plaster  is  guarded  from  .sticking  to  the  malleoH  by 
having  another  piece  stuck  to  its  under  surface  opposite  each 


Fig.  141. — Adhesive  plaster  applied  to  make  extension.     It  should  be  carried  up  higher  to  a 
point  just  below  the  seat  of  fracture. 

of  these  points.  Apply  an  ascending  spiral  reversed  band- 
age over  the  plaster  to  the  groin  (Fig.  141 1,  and  finish  the 
bandage  by  a  spica  of  the  groin.  Slighth'  abduct  the  extrem- 
it\-.  Put  a  brick  under  each  leg  of  the  bed  at  its  foot,  thus 
obtaining  counter-extension  by  the  weight  of  the  body. 
Run  a  cord  over  a  pulley  at  the  foot  of  the  bed,  and  obtain 
extension  by  the  use  of  weights.  From  ten  to  twenty  pounds 
will  probably  be  necessary'  at  first,  but  after  a  day   or  two 


480  DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS. 

from  six  to  eight  pounds  will  be  found  sufficient  (remember 
that  a  brick  weighs  about  five  pounds).  Make  a  bird's-nest 
pad  of  oakum  for  the  heel.  Take  two  canvas  bags,  one  long 
enough  to  reach  from  the  crest  of  the  ilium  to  the  malleolus, 
the  other  long  enough  to  reach  from  the  perineum  to  the 
malleolus.  Fill  the  bags  three-quarters  full  of  diy  sand, 
sew  up  their  ends,  cover  the  bags  with  slips,  and  put  the 
bags  in  place  in  order  to  correct  eversion.     The  slips  may 


Fig.  142. 


Fig.  143. 


Figs.  142,  143. — Cradle  to  keep  clothing  from  leg,  made  from  two  barrel-hoops    (Scudder). 

be  changed  every  third  or  fourth  day.  Keep  the  bed-cloth- 
ing from  coming  in  contact  with  the  foot  by  means  of  a  cradle 
(Figs.  142,  143).  The  bowels  are  to  be  emptied  and  the  urine 
is  to  be  voided  in  a  bed-pan,  unless  using  a  fracture-bed. 
Maintain  extension  for  five  or  six  weeks,  then  mould  paste- 
board splints  upon  the  part,  and  keep  the  patient  in  bed  for 
three  or  four  weeks  more.  In  from  eight  to  ten  weeks  after 
the  accident  the  patient  may  get  about  on  crutches.     Union, 


SPECIAL    FRACTURES. 


481 


if  it  takes  place,  is  usually  cartilaginous,  but  is  sometimes 
bony,  and  there  are  sure  to  be  some  shortening  and  also  some 
stiffness  of  the  joint.  Passive  motion  is  not  made  until  at 
least  eight  weeks  have  elapsed  since  the  accident.  Senn 
claims  that  by  his  method  of  "  immediate  reduction  and 
permanent  fixation "  bony  union  is  obtained  in  fractures 
of  the  neck  of  the  femur  within  the  capsule.  He  "  places 
the  patient  in  the  erect  position,  causing  him  to  stand  with  his 
sound  leg  upon  a  stool  or  box  about  two  feet  in  height ; 
in  this  position  he  is  supported  by  a  person  on  each  side 
until  the  dressing  has  been  applied  and  the  plaster  has  set. 

"  Another  person  takes  care  of  the  fractured  limb,  which 
in  impacted  fractures  is  gently  supported  and  immovably 
held  until  permanent  fixation  has  been  secured  by  the  dress- 
ing. In  non-impacted  fractures  the  weight  of  the  fractured 
limb  makes  auto-extension,  which  is  often  quite  sufficient 
to  restore  the  normal  length  of  the  lim_b  ;  if  this  is  not  the 
case,  the  person  who  has  charge  of  the  limb  makes  traction 
until  all  shortening  has  been  overcome  as  far  as  possible,  at 
the  same  time  holding  the  limb  in  position,  so  that  the  great 
toe  is  on  a  straight  line  with  the  inner  margin  of  the  patella 
and  the  anterior  superior  spinous  process  of  the  ilium.  In 
applying  the  plaster-of-Paris 
bandage  over  the  seat  of 
fracture  a  fenestrum,  cor- 
responding in  size  to  the 
dimensions  of  the  compress 
with  which  the  lateral  press- 
ure is  to  be  made,  is  left 
open  over  the  great  tro- 
chanter. 

"  To  secure  perfect  im- 
mobility at  the  seat  of 
fractures,  it  is  not  only 
necessary  to  include  in  the 
dressing  the  fractured  limb 
and  the  entire  pelvis,  but  it 
is  absolutely  necessary  to 
also  include  the  opposite 
limb  as  far  as  the  knee  and 
to  extend  the  dressing  as  far  as 
eighth  rib. 

"  The  splint  (Fig.  144)  is  incorporated  in  the  plaster-of-Pans 
dressing,  and  it  must  carefully  be  applied,  so  that  the  com- 
press, composed  of  a  well-cushioned  pad  with  a  stiff,  unyield- 

31 


Fig.  144. — Senn's 
apparatus. 


Flc.  145. — Senn's  appa- 
ratus applied. 


the    cartilage    of    the 


482   DISEASES  AND   INJURIES   OF  BONES  'AND  JOINTS. 

ing  back,  rests  directly  upon  the  trochanter  major,  and  the 
pressure,  which  is  made  by  a  set-screw,  is  directed  in  the 
axis  of  the  femoral  neck.  Lateral  pressure  is  not  applied 
until  the  plaster  has  completely  set.  Syncope  should  be 
guarded  against  by  the  administration  of  stimulants. 

"  As  soon  as  the  plaster  has  sufficiently  hardened  to  retain 
the  limb  in  proper  position,  the  patient  should  be  laid  upon 
a  smooth,  even  mattress,  without  pillows  under  the  head, 
and  in  non-impacted  fractures  the  foot  is  held  in  a  straight 
position  and  extension  is  kept  up  until  lateral  pressure  can 
be  applied. 

"  No  matter  how  snugly  a  plaster-of- Paris  dressing  is 
applied,  as  the  result  of  shrinkage  it  becomes  loose,  and 
without  some  means  of  making  lateral  pressure  it  would 
become  necessary  to  change  it  from  time  to  time  in  order 
to  render  it  efficient.  But  by  incorporating  a  splint  in  the 
plaster  dressing  (Fig.  145)  this  is  obviated,  and  the  lateral 
pressure  is  regulated,  day  by  day,  by  moving  the  screw,  the 
proximal  end  of  which  rests  on  an  oval  depression  in  the 
center  of  the  pad." 

Extracapsular  Fracture  {Fracture  of  the  Base  of  the 
Neck). — The  line  of  extracapsular  fracture  is  at  the  junction 
of  the  neck  with  the  great  trochanter,  and  is  partly  within 
and  partly  without  the  capsule,  the  fracture  being  generally 
comminuted  and  often  impacted.  The  cause  is  violent  direct 
force  over  the  great  trochanter  (as  by  falling  upon  the  side 
of  the  hip).  This  fracture  is  most  usual  in  elderly  people, 
but  is  not  very  uncommon  in  young  adults.  Stokes  has 
described  six  forms  of  extracapsular  fracture :  extracapsu- 
lar fracture  with  partial  impaction  posterior ;  fracture  with 
complete  impaction  ;  fracture  with  partial  impaction  above ; 
fracture  with  partial  impaction  below,  the  shaft  being  split ; 
splitting  of  the  neck  longitudinally  without  impaction ;  com- 
minuted non-impacted  fracture.' 

Synnptoms. — When  impaction  is  absent  there  is  marked 
crepitus  on  motion,  which  is  manifested  most  distinctly  when 
the  fingers  are  placed  upon  the  great  trochanter;  there  is 
severe  pain,  pressure  upon  the  great  trochanter  is  very 
painful,  swelling  and  ecchymosis  are  marked  ;  there  is  abso- 
lute inability  on  the  part  of  the  patient  to  move  the  limb, 
and  passive  movements  cause  violent  pain  ;  there  is  shorten- 
ing to  the  extent  of  at  least  one  and  a  half  inches,  and 
sometimes  to  the  extent  of  three  inches,  which  shortening 
is  made  manifest  by  noting  the  ascent  of  the  trochanter  above 

1  Brit.    Med.  Jour.,  Oct.  12,  1895. 


SPECIAL   FRACTURES.  483 

Nelaton's  line,  by  comparison  of  the  injured  limb  with  the 
sound  limb,  and  by  measuring  the  base-line  of  Bryant's 
triangle  on  each  side.  Absolute  eversion  usually  exists 
with  slight  flexion  both  of  the  leg  and  the  thigh.  In  some 
rare  cases  there  is  inversion.  This  happens  if  at  the  time  of 
the  accident  the  limb  was  inverted  and  adducted  (Stokes). 
Lagoria's  sign,  Desault's  sign,  and  Allis's  sign  are  present 
(p.  476).  All  these  symptoms  follow  violent  direct  lateral 
force.  In  the  impacted  form  of  extracapsular  fracture,  in 
addition  to  the  aid  given  the  surgeon  by  the  histon',  there 
is  severe  pain,  which  is  intensified  by  movement  or  press- 
ure ;  shortening  to  the  extent  of  one  inch  at  least,  which 
is  not  corrected  by  extension ;  great  loss  of  function  ;  and 
whereas  the  limb  may  be  straight  or  even  inverted,  it  is 
usually  everted.  The  trochanter  is  above  Nelaton's  line, 
the  base-line  of  Br}-ant's  triangle  is  shortened,  but  not  so 
much  as  in  the  unimpacted  form,  there  is  no  crepitus  unless 
the  impaction  is  pulled  apart,  the  arc  of  rotation  of  the  great 
trochanter  is  larger  than  in  a  non-impacted  fracture,  and 
Allis's  sign  is  noted. 

Treatnieiit. — In  treating  non-impacted  extracapsular  fract- 
ure make  extension,  raise  the  foot  of  the  bed,  and  apply  the 
extension  apparatus  with  sand-bags  for  four  weeks ;  then 
apply  a  plaster  dressing.  Get  the  patient  up  on  crutches 
after  the  plaster  has  been  in  place  for  two  weeks.  Remo\'e 
the  plaster  at  the  end  of  four  weeks.  In  impacted  extra- 
capsular fracture  it  is  best  to  pull  apart  the  impaction  if  the 
patient  is  in  good  physical  condition.  Southam  of  Man- 
chester, in  an  impressive  article,  has  recently  insisted 
on  the  absolute  necessitv^  of  pulling  apart  an  impaction. 
He  gives  ether,  and  when  the  patient  is  anesthetized  un- 
locks the  fragments.^  The  case  is  then  treated  as  described 
above. 

Separation  of  the  upper  epiphysis  of  the  femoral  head 
is  a  veiy  rare  result  of  accident :  it  occurs  most  often  from 
disease  and  in  youth. 

Symptoms  and  Treatment. — The  symptoms  are  like  those 
of  fracture  of  the  neck,  except  that  the  crepitus  is  soft.  The 
treatment  is  extension  as  above  directed. 

Fractures  of  the  Great  Trochanter. — This  process  may 
be  (i)  broken  off  without  any  other  injur}-,  but  in  most  cases 
(2)  the  line  of  fracture  runs  through  the  trochanter,  and 
leav^es  one  portion  of  the  trochanter  attached  to  the  head 
and  neck  and  the    other   part  attached  to  the  shaft  of  the 

^  Lancet,  Dec.  21,  1895. 


484  DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS 

femur.  The  cause  is  violent  direct  force  over  the  great 
trochanter. 

Symptoms  and  Treatment. — The  symptoms  of  the  second 
form  are  similar  to  those  of  extracapsular  fracture.  On 
rotating  the  femur  the  lower  part  of  the  trochanter  moves 
with  it,  but  not  the  upper.  The  lower  fragment  goes  upward 
and  backward  and  projects  by  the  side  of  the  sciatic  notch. 
There  are  shortening,  eversion,  crepitus,  and  altered  position 
of  the  trochanter.  The  symptoms  of  the  first  form  resemble 
those  of  epiphyseal  separation.  The  treatment  of  the  second 
form  is  like  that  in  extracapsular  fracture,  and  the  first 
form  is  treated  like  separation  of  the  epiphysis  of  the 
trochanter. 

Separation  of  the  epiphysis  of  the  great  trochanter  is 
a  very  rare  accident.  The  caiLse  is  direct  violence,  and  the 
injury  occurs  only  in  youth. 

Symptoms. — The  trochanter  is  found  to  have  ascended  and 
passed  posteriorly;  there  is  no  shortening  of  the  thigh;  all 
the  motions  of  the  hip-joint  can  be  obtained ;  if  the  thigh  is 
flexed,  abducted,  and  rotated  externally,  and  the  fragment  is 
pushed  downward  and  forward,  crepitus  is  obtained — soft  in 
epiphyseal  separation,  hard  in  fracture. 

Treatment. — In  treating  separation  of  the  epiphysis  of  the 
great  trochanter  flex  the  leg  on  the  thigh  and  the  thigh  on 
the  pelvis,  place  the  extremity  upon  its  outer  surface,  keep  it 
fixed  by  some  form  of  retentive  apparatus,  and  tr>^  to  draw 
the  trochanter  downward  and  forward  by  adhesive  strips  or 
by  a  pad  and  bandage.  Some  degree  of  lameness  is  inevi- 
table, even  after  Bryant's  extension.  Br)^ant's  extension 
directly  upv/ard  may  admit  of  the  trochanter  being  pulled 
into  place  upon  the  bone  (Fig.  150).  Extension  must  be 
applied  for  six  weeks,  and  crutches  and  pasteboard  splints 
should  be  used  for  four  weeks  more. 

2.  Fractures  of  the  shaft  of  the  femur  may  affect  any 
portion  of  the  shaft,  but  especially  the  middle  third,  and  may 
occur  at  any  age.  Fracture  of  the  upper  third  is  a  rare  acci- 
dent. Allis  estimates  that  each  year  in  Philadelphia  there  is 
I  case  to  every  100,000  inhabitants.  Separation  of  the  lower 
epiphysis  occasionally  occurs.  The  cause  of  fractures  in 
the  upper  third  is  usually  indirect  force;  fractures  in  the 
lower  third  are  due  to  direct  force  ;  and  in  fractures  of  the 
middle  third  these  two  causes  are  about  equally  potential. 
Fracture  from  muscular  action  occasionally  occurs.  Oblique 
fracture  is  the  usual  variety. 

Symptoms. — The  chief  symptom  in  fracture  of  the   shaft 


SPECIAL   FRACTURES.  485 

of  the  femur  is  great  displacement,  except  when  impaction 
occurs,  when  the  break  is  due  to  direct  force,  or  wlien  the 
injury  is  in  a  child.  In  a  child  the  line  of  fracture  is  often 
transverse  and  the  periosteum  ma\'  be  untorn,  and  green-stick 
fractures  occur  in  children.  As  a  rule,  in  fracture  of  the 
shaft  of  the  femur  the  lower  fragment  is  drawn  upward  and 
the  upper  end  of  the  lower  fragment  is  found  posterior  and 
somewhat  to  the  inside  of  the  lower  end  of  the  upper  frag- 
ment, and  the  lower  fragment  also  undergoes  external  rota- 
tion (the  drawing  up  is  due  to  the  rectus  and  hamstrings ; 
the  passing  inward  is  due  to  the  adductor  muscles;  the  rota- 
tion outward  arises  from  the  weight  of  the  limb).  If  a  fracture 
of  the  lower  two-thirds  of  the  shaft  is  produced  by  direct 
force,  there  is  usually  but  little  deformity,  because  the  line 
of  fracture  is  nearly  transverse.  If  produced  by  indirect  force, 
there  is  often  great  deformity,  the  line  of  fracture  being 
oblique.  In  fracture  of  the  lower  third  of  the  shaft  the 
gastrocnemius  pulls  upon  the  cond3-les  and  tilts  the  lower 
fragment,  so  that  its  upper  end  projects  into  the  popliteal 
space  and  may  damage  the  vessels.  In  fracture  of  the  upper 
third  the  upper  fragment  is  apt  to  be  thrown  strongh'  for- 
ward and  outward.  Some  attribute  this  to  the  action  of  the 
psoas.  iHacus.  and  external  rotator  muscles,  but  Allis  thinks 
it  is  due  chiefly  to  the  lower  fragment  pushing  the  upper 
fragment  into  this  position,  a  part  of  the  tendon  of  the  gluteus 
maximus  acting  as  a  hinge  for  the  fragments.^  In  rare  cases 
the  angular  deformity  is  backward.  In  fracture  of  the  shaft  of 
the  femur  there  is  complete  loss  of  function,  the  thigh  and 
leg  being  semiflexed  and  everted.  There  are  shortening  to 
the  extent  of  two  or  three  inches,  pain  on  movement,  preter- 
natural mobility,  crepitus,  and  obvious  deformity,  and  the 
ends  of  the  fragments  can  be  felt  b\-  the  surgeon.  In 
impaction  there  is  alteration  of  the  axis  of  the  limb  and  some 
shortening. 

Treatment. — In  fracture  of  the  shaft  of  the  femur,  if 
impaction  exists,  the  fragments  must  be  pulled  apart,  when 
the  case  should  be  treated  exactly  as  is  a  non-impacted 
fracture.  After  a  fracture  of  the  shaft  of  the  femur  some 
amount  of  permanent  shortening  is  almost  inevitable.  In 
fracture  of  the  upper  third  treatment  is  usually  unsatis- 
factoiy,  and  there  is  permanent  shortening  from  angular 
union  or  from  overlapping.  Horizontal  extension  fails  to 
correct  the  displacement  of  the  upper  fragment  in  fracture 

1  ■•  Fracture  in  the  Upper  Third  of  the  Femur  Exclusive  of  the  Neck,"  by 
Oscar  H.  Allis,  Medical  News,  Nov.  21,  1891. 


486   DISEASES  AND    INJURIES    OF  BONES  AND  JOINTS. 


of  the  upper  third.  The  double  inclined  plane  will  not  correct 
the  tilting-  of  the  upper  fragment  while  shortening  exists. 
Agnew  used  a  double  inclined  plane  and  corrected 
shortening  by  the  use  of  extension  in  the  axis  of  the 
partly-flexed  thigh  (Fig.  146).     This  plan  is  the  most  ser- 


FiG.  146.— Dressing  of  fracture  of  the  femur  in  the  upper  third  with  extension  upon  a  double 
incUned  plane  (Agnew). 

viceable  of  those  usually  employed,  but  it  too  fails  to  com- 
pletely correct  the  displacement.  If,  notwithstanding-  posi- 
tion and  extension,  the  upper  fragment  projects,  it  should  be 
pushed  into  place  and  be  retained  if  possible  by  short  splints 
bound  upon  the  thigh.  Extension  should  be  continued  for 
four  weeks,  a  plaster-of-Paris  bandage  being  used  for  four 
weeks  more,  the  patient  being  then  allowed  to  go  about  on 
crutches.  Some  surgeons,  in  fracture  of  the  upper  third, 
apply  a  plaster-of-Paris  bandage  to  the  leg,  thigh,  and  pelvis, 
extension  being  made  from  the  foot  while  the  dressing  is  being 

applied.  This  method 
does  not  give  good  re- 
sults because  such  ex- 
tension will  not  correct 
the  tilting  of  the  upper 
fragment.  The  anterior 
splint  of  Nathan  R. 
Smith  is  used  by  some 
in  treating  fractures  of 
the  upper  third  of  the 
femur  (Fig.  147).  It  is 
bent  to  the  desired  shape, 
fastened  to  the  anterior 
surfaces  of  the  leg  and 
thigh,  and  hung  to  a 
gallows,  the  limb  being 
suspended  at  tlie  desired 
height.     This   splint  is  open   to   the   same  objection  as   the 


Pig.  147.— Smith's  anterior  splint. 


SPECIAL    FRACTURES. 


487 


double  inclined  plane.  Some  surgeons  use  Hodgen's  appa- 
ratus, but  it  is  not  satisfactory-.  In  fact,  in  fractures  of  the 
upper  third  of  the  shaft  of  the  femur  no  apparatus  will  main- 
tain reduction.  In  such  cases  it  is  advisable  to  incise, 
separate  the  muscle  from  between  the  fragments,  and  fasten 


Fig.  148.— Hodgen's  apparatus  as  applied  by  Dr.  George  S.  Brown. 


the  ends  together  w4th  bone  ferrules,  silver  wire,  kangaroo- 
tendon,  steel  screws,  steel  pins,  or  a  bone-clamp.  This  radical 
treatment  has  certain  dangers  of  its  own  but  it  is  the  only 
plan  which  promises  to  secure  a  thoroughly  good  limb.  In 
fracture  of  the  middle  third  or  upper  part  of  the  lower  third 


488    DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 


of  the  shaft  of  the  femur,  the  extension  apparatus  and  sand- 
bags will  usually  secure  a  satisfactory  result  (PI.  6,  Fig.  14). 
The  strips  of  adhesive  plaster  are  carried  to  just  below  the 
seat  of  fracture,  and  the  turns  of  the  roller  bandage  should 
be  taken  to  a  little  above  this  point.  Extension  should  be  con- 
tinued for  four  weeks,  when  the  plaster-of- Paris  bandage  ought 
to  be  applied.  The  plaster  is  kept  in  place  for  four  weeks. 
Many  surgeons  use  Hodgen's  splint  in  treating  fractures  of 
the  thigh.  The  limb  is  suspended  in  a  cradle  and  extension 
is  obtained  by  strapping  the  foot  to  the  cross-bar  of  the  frame 
and  pulHng  upon  the  frame  by  cords  (Fig.  148).  In  fract- 
ure of  the  middle  third  or  upper  part  of  the  lower  third  of  the 
shaft  if  the  line  of  fracture  is  transverse  and  there  is  little 
deformity,  as  is  seen  often  after  a  fracture  by  direct  force, 
and  often  in  children,  immobilization  in  an  im- 
movable dressing  may  be  all  that  is  required  ; 
but  if  shortening  exists,  extension  must  be  used. 
If  extension  is  used,  continue  it  for  four  weeks 
and  then  substitute  a  plaster-of-Paris  dressing 


Fig.  149. — Mclntyre's  splint. 

for  four  weeks.  The  amount  of  weight  required  is  pointed  out 
by  Dawbarn  :  one  pound  for  each  year  up  to  twenty.^  In  fract- 
ure near  the  knee-joint  it  may  be  impossible  to  effect  reduc- 
tion by  horizontal  traction.  In  such  a  case  make  traction, 
and  while  it  is  being  made  gradually  bring  the  leg  to  a  right 
angle.  Place  the  limb  in  a  double  inclined  plane  (PI.  6, 
Fig.  2).  A  Mclntyre  splint  (Fig.  149)  is  a  useful  form 
of  double  inclined  plane.  After  four  weeks  of  the  use  of 
a  double  inclined  plane  apply  a  plaster-of-Paris  dressing,  which 
is  to  be  worn  for  four  weeks. 

Fractures  of  the  Thigh  in  Children. — In  children  under 
three  years  of  age  the  extension  apparatus  will  not  satisfac- 
torily immobilize  the  fragments.     Fractures  of  the  thigh  in 


^  Actuals  of  Sti7'geryy  Oct.,  1897 


SPE  CIA  L    FKA  C  TURKS. 


489 


children  are  reduced  by  extension  and  counter-extension  ;  a 
well-padded  splint  reaching  from  the  axilla  to  below  the  sole 
of  the  foot  is  applied  to  the  outer  side  of  the  limb  and  body. 
This  splint  is  held  in  place  by  bandages  which  are  overlaid 
with  plaster-of-Paris.  It  is  worn  for  four  weeks,  at  which 
time  it  is  removed  and  a  plaster  bandage,  applied  so  as  to 
include  the  entire  limb,  is  worn  for  four  weeks  more. 

Bryant's  extension  is  very  satisfactory  in  treating  a  child 
(Fig.  150).  Both  the  injured  limb  and  the  sound  limb  should 
be  flexed  to  a  right  angle  with  the 
pelvis,  fixed  by  light  splints,  and  fas- 
tened to  a  bar  above  the  bed.  The 
weight  of  the  body  produces  counter- 
extension  and  the  child  can  be  easily 
cleaned.^ 

Another  plan  is  that  of  Theodore 
Dunham.-^  The  child  is  placed  upon 
a  table,  and  the  knee  and  thigh  are 
partly  flexed.  After  first  applying 
flannel  rollers,  plaster-of-Paris  band- 
ages are  applied  from  the  roots  of 
the  toes  to  the  spine  of  the  tibia, 
and  as  a  spica  about  the  upper 
part  of  the  thigh  and  pelvis.  Two 
pieces  of  iron,  suitably  bent,  are  used 
to  anchor  the  two  plaster  bandages 
together.  One  end  of  one  iron  is 
attached  to  the  plaster  over  the  groin 
and  one  end  of  the  other  iron  is  attached  to  the  plaster  over 
the  front  of  the  leg.  The  free  ends  of  the  irons  overlap.  At 
the  points  over  the  joint  and  the  front  of  the  leg  where  the 
irons  are  to  rest  masses  of  plaster  are  placed.  The  iron  is 
sunk  into  the  plaster  and  supported  at  each  spot  by  several 
turns  of  a  plaster  bandage.  While  the  irons  are  being 
adjusted  the  thigh  is  so  held  as  to  prevent  bending  or  rota- 
tion, and  the  hip  and  knee  are  semiflexed.  When  the  plaster 
has  set,  an  assistant  makes  extension  on  the  leg  and  another 
assistant  makes  counter-extension  by  pressing  on  the  pelvis. 
Any  shortening  is  thus  reduced  and  the  two  irons  are  lashed 
together  with  strong  cord  (Fig.  151). 

Van  Arsdale's  triangular  splint  is  a  ver>^  useful  appliance. 
It  is  made  of  binders'  board.     A.  Ernest  Gallant''  describes 

1  Bryant's  Practice  of  Surgery. 

2  Pkila.  Med.  Jour.,  April  23,  1898. 
^Jour.  Amer.  Med.  Assoc,  Dec.  18,  1897. 


Fig.  150. — Bryant's  extension 
for  fracture   of   the    thigh  in   a 

child. 


490   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 


its  preparation  and  application  as  follows  :  Measure  the  length 
of  the  sound  thigh  from  the  middle  of  the  groin  to  the  end  of 
the  femur.  Draw  upon  cardboard  an  outline  of  a  double 
spade  (playing-card  spade),  Fig.  152.  Each  of  the  four  sec- 
tions {A,  B,  C,  D)  must  be  equal  to  the  length  of  the  child's 
thigh,  the  flanged  portions  being  equal  to  the  widest  part 
of  the  thig-h.  The  fip-ure  is  then  cut  out.  The  cardboard 
is  moistened  on  one  side  and  folded  on  the  dotted  Ime, 
section  A  being  lapped  over  D,  so  as  to  form  a  triangle. 
It  is  fastened  together  by  adhesive 
plaster.  The  thigh  is  flexed  and  the 
triangle  is  applied  so  that  one  flanged 
portion  embraces  the  thigh  and  the 
other  flanged  portion  rests  on  the  ab- 
domen The  triangle  is  fixed  in  po- 
sition by  bandages,  figure-of-8  turns 
being  made  around  the  knee  and 
around  the  thigh  and  body.  Plaster 
or  starch  bandages  are  then  applied 
to  fix  the  splint  firmly.  The  leg 
should  be  bandaged  from  the  toe  to 
the  knee  to  prevent  swelling  (Fig. 
153).  This  splint  is  worn  for  three 
weeks.  A  child  wearing  this  splint 
can  sit  on  a  chair,  nurse,  play  on  the 
floor  and  crawl  about,  may  sleep  on 
either  side,  and  the  dressing  is  not 
soiled  by  the  evacuations. 

If  a  thigh  is  fractured  during  par- 
turition, or  during  the  first  few  weeks 
of  life,  Wyeth's  dressing  is  very  ser- 
viceable. It  is  applied  as  follows : 
The  leg  is  flexed  on  the  thigh  and 
the  thigh  on  the  abdomen.  A  flannel 
bandage  is  applied  so  as  to  include  the  leg,  the  thigh,  and 
the  body  from  the  axilla  to  the  pelvis.  Plaster  of  Paris  is 
applied  over  this ;  the  dressing  is  worn  for  four  weeks. 

Fractures  Just  Above  the  Condyles  of  the  Femur. — 
The  line  of  fracture  above  the  condyles  is  well  above  the 
epiphyseal  line.  The  femoral  artery  is  in  danger  from  the 
fragments.  The  cause  of  the  break,  as  a  rule,  is  direct 
violence.  Indirect  force  is  sometimes  responsible  (falls  upon 
the  feet).  The  knee-joint  may  be  opened.  The  fracture  is 
sometimes  compound. 

Symptoms. — The    upper    end    of    the    lower    fragment    is 


Fig.  151. — Dunham's  appa- 
ratus for  treating  fractures  of  the 
thigh  in  infants  and  children. 


SPE  CIA  L    FRA  C  TURES. 


491 


drawn  upward  and  backward,  because  of  the  action  of  the 
rectus  hamstrings,  gastrocnemius,  and  pophteus.  1  he  upper 
fracrment  passes  inward,  and  the  deformity  is  veiy  manifest 
Th?re  are  shortening,  crepitus,  and  mobihty.  The  ends  ot 
the  fragments  can  be  felt  by  the  surgeon^  If  the  force  has 
been  ^ir^^  o-reat,  a  T-fracture  results.    In  T-fracture  the  knee 


Fig  IS' -I  DiaCTam  showing  outline  of  Van  Arsdale's  sphnt  The  end  band  to  be 
folded  on 'the  dotted  li^es  :  each  section  to  equal  the  length  of  the  ch.ld  s  th.gh  ..  D.agratn. 
spUnt  folded,  fastened  by  rubber  plaster,  flanges  bent  to  en^brace  the  th.gh  and  abdomen, 
ready  for  adjustment  (Gallant). 

is  broadened  and  crepitus  is  obtained  by  moving  the    con- 
dyles, one  up  and  the  other  down. 

Treatment.— In  treating  fracture  above  the  condyles,  reduce 
the  deformity  by  horizontal  extension.  If  this  fails,  make 
traction  at  the  same  time,  gradually  bringing  the  leg  to  a  right 
ano-le  with  the  thigh.  Place  the  Hmb  on  a  double  inclined 
plalie  for  f^ve  weeks,  then  begin  passive  motion  once  every 


Fig.  xS3.-Showing  Van  Arsdale's  triangular  splint  in  P-i"°"-  N"te  t'^'  ""^'  ''""  ''"""° 
153  =    ^^^  dressings  and  the  excretory  passages  (Gallant). 

other  dav,  restoring  the  limb  to  the  splint  after  the  movements 
are  completed.  At  the  end  of  eight  weeks  after  the  accident 
remove  the  dressings,  and.  if  the  knee-joint  be  stiff,_  use  for 
some  time  massage,  motions,  hot  and  cold  douches,  ichthyol 
inunctions,  etc.  Brvant  treats  this  fracture  in  extension,  cut- 
tincT  the  tendo  Achillis.  if  necessar\%  to  amend  deformity.  It 
is  occasionally  necessary  to  wire  the  fragments.     Some  cases 


492    DISEASES  AND   INJURIES   OE  BONES  AND  JOINTS. 

demand  amputation  because  of  injury  to  the  structures  in  the 
popliteal  space. 

Fracture  Separating-  Either  Condyle. — The  cause  of  this 
fracture  is  direct  force. 

Symptoms  and  Treatment. — The  broken  piece  is  drawn 
upward,  the  leg  bends  toward  the  injury,  crepitus  exists,  the 
knee  is  much  broadened,  there  is  no  shortening,  and  con- 
siderable swelling  is  sure  to  arise.  In  treating  a  fracture 
separating  either  condyle,  u.se  a  double  inclined  plane  as 
directed  above. 

Longitudinal  fractures  run  Upward  from  the  knee-joint. 
The  canse  is  a  fall  upon  the  feet  or  the  knees. 

Symptoms  and  Treatment. — The  symptoms  of  longitudinal 
fracture  are  often  obscure.  The  femur  is  broadened  when 
the  knee  is  flexed.  The  split  may  be  detected  between  the 
condyles.  The  treatment  is  the  straight  position  in  plaster 
for  eight  weeks. 

Separation  of  the  lower  epiphysis  occurs  only  before  the 
twenty-first  year.     It  is  not  a  very  rare  accident  in  children. 

Symptoms. — The  .symptoms  in  separation  of  the  lower 
epiphysis  are  like  those  of  transverse  fracture,  but  crepitus  is 
moist.  The  lower  fragment  is  tilted,  so  that  the  articular 
surface  looks  forward.  The  lower  end  of  the  upper  fragment 
projects  into  the  popliteal  space.  The  danger  is  that  the 
growth  of  bone  will  be  stunted. 

Treatment. — Reduction  may  be  effected  in  some  cases  by 
horizontal  extension.  Occasionally  this  is  impossible.'  In 
such  a  case  adopt  the  plan  of  Hutchinson  and  Barnard,  make 
extension,  and  while  it  is  being  made  gradually  place  the  leg 
at  a  right  angle  to  the  thigh.  This  is  effected  by  an  assistant 
making  traction  on  the  leg,  while  the  surgeon  clasps  his 
hands  beneath  the  lower  part  of  the  thigh  and  draws  upward. 
The  treatment  for  separation  of  the  lower  epiphysis  is  the 
use  of  a  double  inclined  plane  as  above  directed. 

Fracture  of  the  patella  is  a  very  common  accident.  The 
cause  is  direct  force  (producing  vertical,  star-shaped,  or 
oblique  lines  of  fracture)  or  muscular  action  (producing  a 
transverse  line  of  fracture). 

Fractures  of  the  Patella  by  Muscular  Action. — The 
knee-cap  is  more  often  broken  by  muscular  action  than  is 
any  other  bone.  When  the  knee  is  partly  flexed  the  middle 
third  of  the  patella  rests  upon  the  condyles  of  the  femur  and 
the  upper  third  of  the  knee-cap  projects  above  them ;  when 

^  See  the  case  reported  by  Jonathan   Hutchinson,  Jr.,  and   Harold   L.  Bar- 
nard, Lancet,  May  13,  1899. 


SPECIAL    FRACTURES. 


493 


in  this  position  a  contraction  of  the  quadriceps  may  easily 
cause  a  fracture  near  the  center  of  the 
bone  (Fig.  154).  The  accident  may  be 
caused  by  sudden  flexion  of  the  knee 
when  the  quadriceps  is  contracting.  The 
most  usual  cause  is  a  fall  or  an  attempt 
of  the  patient  to  save  himself  from  a  fall. 
Both  patellae  may  be  broken  at  once.  In 
fracture  of  the  patella  the  joint,  and  often 
the  prepatellar  bursa,  is  opened.  Fract- 
ures by  muscular  action  are  transverse. 
The  injury  is  more  common  in  males  than 
in  females,  and  is  extremeh'  rare  in  the  ver}^  young  and  the 
old.     It  is  an  injur}^  of  acti\e  manhood  and  middle  life. 


Fig.  154. — Mechanism  of 
fracture  of  the  patella  by  mus- 
cular action   (after  Treves). 


Fig.   155. — Fracture  of  the  patella  (Pennsylvania  Hospital  case;  skiagraphed  by  Dr.  Gaston 

Torrance) 

Svniptoms. — When  the  accident  happens  there  is  often  an 
audible  crack.     As  a  rule,  the  patient  will  not  try  to  use  the 


494   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

limb,  although  it  is  possible  for  him  to  stand,  to  walk  backward, 
and  to  move  slowly  forward  when  the  extremity  is  kept  straight. 
After  the  accident  there  is  rapid  and  enormous  swelling, 
due  to  the  effusion  first  of  blood  and  then  of  synovia  and  in- 
flammatory products  into  and  around  the  joint.  The  patient 
is  absolutely  unable  to  raise  the  limb  from  the  bed.  The  frag- 
ments are  movable  and  usually  widely  separated  (Fig.  155), 
this  separation  being  distinctly  manifest  to  the  touch  unless 


Fig.  156. — Fracture  of  the  patella  (Pennsylvania  Hospital  case  :  skiagraphed  by  Dr.  Gaston 

Torrance). 


swelhng  is  great.  The  separation  is  accentuated  by  flexion  of 
the  leg.  The  separation  may  be  to  the  extent  of  one  inch  or 
even  more.  In  cases  in  which  the  lateral  fibrous  expansions  and 
periosteum  are  but  slightly  torn,  there  may  be  slight  separa- 
tion or  no  separation.  Separation  is  due  in  part  "  to  the 
retraction  of  the  quadriceps  and  the  tension  of  the  fascia  lata, 
and  in  part  to  distention  of  the  joint  by  blood  and  exudate."  ^ 

1  Stimson's  Treatise  on  Fractures  and  Dislocations. 


SPECIAL    FRACTURES. 


495 


LwC;! 


liiV 


% 


'II ;  '  irnin 


Fig.  157. — Transverse  fracture  of  the 
patella  ;  fractured  surface  partially  cov- 
ered by  irregular  flaps  of  torn  apo- 
neurosis  (Hoffa). 


If  fragments  are  not  approximated  and  union  does  not 
occur,  the  separation  becomes  gradually  greater  because  of 
the  progressive  shortening  of  the 
muscle  and  the  retraction  of  the 
ligamentum  patellae  (Stimson). 
In  some  cases  an  anterior  angu- 
lar displacement  occurs  because 
of  the  intra-articular  distention 
(Fig.  156).  It  may  be  produced 
by  the  pressure  of  bandages  or 
strips  of  plaster  when  the  frag- 
ments have  been  brought  to- 
gether. Crepitus  is  detected  if 
the  upper  fragment  can  be 
pushed  down  until  it  touches 
the  lower  piece ;  but  if  swelling 
is  great,  or  if  fibrous  tissue  is 
interposed  between  the  bones, 
crepitus  cannot  be  elicited.  It 
is  useless  to  seek  for  it,  as  the 
diagnosis  is  obvious  without  this 
sign.  The  anterior  fibroperios- 
teal   layer  is   torn,  and  the  tear 

does  not  correspond  exactly  with  the  line  of  fracture.  A 
portion  of  this  torn  fibroperiosteal  layer  may,  as  Macewen 
pointed  out,  pass  between  the  fragments  and  prevent  union 
(Fig.  157).  The  lateral  expansions  of  the  capsule  are  usually 
extensively  torn.  Union,  if  it  occurs,  will  probably  be  liga- 
mentous, and  if  the  patient  gets  about  too  soon,  even 
apparently  well-united  fragments  will  by  degrees  stretch  far 
asunder. 

Treatment  of  Transverse  Fractures  of  the  Patella. — If 
in  transverse  fracture  of  the  patella  the  swelling  is  so  great 
as  to  prevent  approximation  of  the  fragments,  reduce  it  by 
bandaging  for  a  day  or  two,  by  using  ice-bags,  or  by  aspi- 
rating the  joint.  As  a  rule,  the  blood  does  not  coagulate  for 
several  days.  After  it  coagulates  it  cannot  be  withdrawn  by 
aspiration,  but  only  by  incision.  When  the  swelling  di- 
minishes, bring  the  two  fragments  into  apposition,  pull  them 
together  by  adhesive  plaster,  and  put  on  a  well-padded  pos- 
terior splint.  Carry  a  piece  of  adhesive  plaster  over  the  upper 
end  of  the  upper  fragment,  draw  the  bone  down  and  fasten 
the  plaster  behind  and  below  the  joint.  Carry  another  piece 
of  plaster  over  the  lower  end  of  the  lower  fragment,  draw  the 
bone  up,  and  fasten  the  plaster  behind  and  above  the  joint. 


496  DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

Cany  a  third  piece  ov^er  the  junction  of  the  fragments  to 
prevent  tilting.  Agnew's  splint  admirably  accomplishes  this 
approximation  (PL  6,  Figs,  ii,  12).  A  bandage  holds  the 
splint  in  place,  and  may  be  carried  around  the  knee  by  figure- 
of-8  turns.  The  heel  is  sometimes  raised  upon  a  pillow  so 
as  to  extend  the  leg  and  to  semiflex  the  thigh,  but  this  is  not 
essential.  Remove  and  reapply  the  dressing  every  few  days, 
as  it  inevitably  becomes  loose.  At  the  end  of  three  wrecks 
remove  the  splint  permanently  and  apply  a  plaster-of- Paris 
dressing  from  just  above  the  ankle  to  the  middle  of  the  thigh, 
and  get  the  patient  about  on  crutches.  The  dressing  is  to  be 
worn  for  five  weeks.  After  eight  weeks  of  treatment  allow  the 
patient  to  walk  with  canes,  the  joint  being  kept  fixed  for  four 
weeks  more  by  pasteboard  splints  or  by  a  light  plaster-of-Paris 
bandage.  For  one  year  after  removing  the  splints  and 
plaster  a  lacing  knee-cap  of  leather  should  be  w^orn  in  the 
daytime  to  support  the  joint.  The  plan  of  prolonged  immo- 
bilization renders  more  or  less  joint-stiffness  a  certain  occur- 
rence, but  this  is  less  of  an  impediment  than  the  wide  separa- 
tion of  the  fragments  that  inevitably  attends  an  early  use  of 
the  joint.  Biyant  of  New  York  has  devised  an  ambulatory 
dressing. 

Malgaigne's  hooks  are  practically  obsolete. 

It  is  said  that  John  Rhea  Barton  wired  an  ununited 
fracture  of  the  patella  in  1843.  I^  ^'^77  Hector  Cameron 
wired  an  ununited  fracture  of  the  patella,  and  a  few  months 
later  Lord  Lister  operated  on  a  fracture  of  the  knee-cap  two 
weeks  after  the  accident.  The  question  of  the  advisability  of 
suturing  a  recent  fracture  is  verj^  much  disputed.  The  ordi- 
nary non-operative  plans  of  treatment  do  not  endanger  life  and 
usually  give  a  good  functional  result.  The  operative  method 
will  usually  succeed,  and  is  capable  of  obtaining  a  better  func- 
tional result  and  of  obtaining  it  more  rapidly.  There  is  some 
danger  of  infection,  and  if  infection  should  occur  the  results 
will  be  most  disastrous.  Some  cases  obviously  cannot  be 
treated  by  the  ordinary  method  with  any  chance  of  success  ; 
cases,  for  instance,  in  which  a  flap  of  fibroperiosteum  inter- 
venes between  the  fragments,  or  cases  in  which  from  some 
other  cause  the  bones  cannot  be  approximated.  Such 
cases  should,  of  course,  be  operated  upon.  But  in  the 
great  majority  of  cases  a  good  result  will  follow^  conservative 
treatment,  and  conservative  treatment  should  be  trusted  to 
unless  the  case  is  in  the  hands  of  a  surgeon  and  in  a  place 
where  every  antiseptic  precaution  can  be  taken.  We  agree 
with  Stimson  when  he  says  that  operative  methods  can  be 


SPECIAL    FRACTURES. 


497 


used  with  confidence  when  surrounded  with  every  protection  ; 
he  habitually  uses  them,  but  he  never  teaches  them  as 
proper  routine  practice,  and  strongly  advises  against  their 
use  except  by  those  who  have  had  experience  in  operating, 


Fig  15S  —Needle  specially  desianed  to  carrv  a  thick  wire.  The  eye  is  drilled  obliquely, 
and  siiould  receive  only  a  little  loop  on  the  end  of  the  wire  ;  this  loop  should  be  made  pre- 
viously . 

who  have  formed  the  habit  of  taking  precautions,  and  who  have 
the  aid  of  skilled  assistants.^  Operation  should  only  be  per- 
formed on  health}-  persons  of  suitable  age,  when  the  separa- 


FlG.  159.— Needle  {a)  introduced  behind  the  fragments,  and  receiving  one  end   (b)   of  the 
silver  wire  ((5,  C-)  (Barker). 

tion  is  over  one-half  an  inch  or  when  there  is  much  laceration 
of  the  capsule.-  Barker  believes  strongh'  in  wiring  recent 
transverse  fractures.    He  does  it  with  antiseptic  care  soon  after 

^  Annals  of  Surgery,  August,  1898. 

*  Powers,  in  Annals  of  Surgery,  July,  1898. 

32 


498   DISEASES  AND    INJURIES    OF  BONES  AND  JOINTS. 


the  accident,  and  permits  passive  motion  or  even  slight  active 
motion  immediately  after  the  operation.    Massage  is  becjun  the 

day 


and 
two 


after    the    operation, 
is  practised  daily  for 


special 
j8)  and  sil- 


FiG.  160. — Needle  {11)  passed  in  front  of  the 
fragments  and  receiving  the  other  end  (c)  of  the 
silver  wire  (^,  r)   (Barker). 


weeks. 
Barker  ^  uses 
needle  (Fig.  i; 
ver  wire  of  the  thickness 
of  a  No.  I  English  catheter. 
This  wire  is  straightened 
and  softened  in  a  spirit- 
flame.  He  rubs  the  frag- 
ments together  in  order  to 
dislodge  blood  or  fibrous 
material,  and  when  marked 
grating  occurs  he  intro- 
duces the  wire.  A  punct- 
ure with  a  small  knife  is 
made  through  the  middle 
of  the  upper  attachment  of 
the  patellar  ligament.  The 
needle,  not  carrying  any 
wire,  is  made  to  enter 
through  this  opening  into 
the  joint,  is  passed  back  of 
the  fragments,  pierces  the  tendon  of  the  quadriceps  at  the  upper 
edge  of  the  upper  fragment,  and  its  point  is  cut  upon  with  a 
knife.  The  wire  is  inserted  into  the  eye  of  the  needle  and  the 
needle  is  withdrawn  and  unthreaded.  The  empty  needle  is 
pushed  through  the  lower  opening,  is  carried  in  front  of  the 
joint,  is  made  to  emerge  at  the  upper  opening,  is  threaded  again 
and  withdrawn  (Figs.  159,  160).  The  wires  arc  threaded  into 
bars  and  twisted  (Fig.  161).  There  are  objections  to  Barker's 
operation :  It  does  not  allow  us  to  remove  blood-clots  from 
the  joint;  if  a  bit  of  tissue  intervenes  between  the  fragments, 
it  cannot  be  removed ;  and  a  foreign  body  is  left  permanently 
in  the  joint.^  If  an  operation  is  thought  advisable,  we  deem  it 
best  to  do  an  open  operation,  making  a  central  incision,  free- 
ing the  joint  from  blood-clots  by  irrigation  with  hot  salt  solu- 
tion, removing  all  tissue  from  between  the  fragments,  drilling 
the  fragments,  passing  silver  wire,  twisting  the  wire  and  draw- 
ing the  fragments  together,  and  closing  the  wound  (Fig.  162). 

^  See   the  objections    of  Sir  William   Stokes  to   Barker's   method,  in    Brit. 
Med.  Jour..,  Dec.  3,  1898. 

*  Brit.  Med.  Jour.,  April   11,  1896. 


SPECIAL   FRACTURES. 


499 


Instead  of  wire,  silk  may  be  used.  In  cases  in  which  there  is 
no  \"er}'  strong  tendency  to  separation  the  fragments  can  be 
held  together  by  several  catgut  sutures  through  the  periosteum 
at  the  iractured  edges  or  by  a  strong  catgut  suture  passed 
through  the  ligamentum  patellce  and  the  quadriceps  tendon 
and  carried  in  front  of  the  fracture  (Stimson).  The  limb 
should  be  placed  on  a  posterior  splint.  In  seven  or  eight 
days  the  superficial  sutures  are  remoxed  and  a  plaster-of- 
Paris  splint  is  applied.  In  a  few  days  the  patient  gets  about 
on  crutches.  In  a  month  the  dressing  is  cut  down  the  front 
and  worn  only  in  the  day-time,  and  passive  motion  is  begun. 
The   splint    is    discarded    at   the    end  of  the    third    month.^ 


Fig.  i6i. — Wire  in  position  round  fragments  and  threaded   through   metal  bars.     The  lower 
and  posterior  wire  runs  upward  to  the  left  of  the  upper,  ready  for  twisting  (Barker). 

Among  other  operative  procedures  w^e  may  mention  the  fol- 
lowing :  Encircling  the  fragments  with  a  silk  suture  (the  cir- 
cumferential suture).  This  suture  may  impair  bone  nutrition 
and  retard  union.  Ceci  drills  the  bones  subcutaneously  and 
passes  wire  through  the  drill-holes  in  the  form  of  a  figure-of-8. 
Passing  subcutaneously  a  ligature  around  and  over  the  frag- 
ments (Butcher).  Incision  and  approximation  of  the  frag- 
ments by  fixation-hooks  or  metal  pins. 

Fractures  of  the  patella  by  direct  force  are  \'ertical, 
stellate,  oblique,  or  V-shaped,  are  often  incomplete  and  oc- 
casionally compound  or  comminuted. 

1  Stimson,  Annals  of  Surgery,  August,  1898. 


500    DISEASES  AND   EYJCRIES   OF  BONES  AND  JOINTS. 

Symptoms.— Yx2i.cX.\xx&?>  of  the  patella  by  direct  force  are 
followed  by  discoloration,  swelling,  great  difficulty  in  move- 
ment, and  much  pain.  There  may  or  may  not  be  crepitus. 
The  degree  of  separation  of  the  fragments  depends  upon  the 


Fig.  162. — Wired  fracture  of  the  patella  (St.  Joseph's    Hospital  case;   operated  upon  and 
skiagraphed  by  Dr.   Nassau). 


direction  of  the  line  of  fracture,  and  the  extent  of  bone  involved. 
Bony  union  is  apt  to  occur  after  such  a  fracture. 

Treatment. — A  fracture  resulting  from  direct  force  may 
often  be  treated  with  a  posterior  splint  and  the  application 
of  a  bandage.  If  there  is  any  separation,  the  fragments  should 
be  approximated  by  adhesive  strips,  bandages,  and  compresses. 
At  the  end  of  three  weeks  remove  the  posterior  splint,  ap- 


SPECIAL    FRACTURES.  50I 

ply  a  plaster-of-Paris  splint,  and  get  the  patient  about  on 
crutches.  The  danger  in  these  cases  is  ankylosis  rather  than 
non-union  ;  hence,  in  the  fourth  week,  cut  the  plaster  splint 
down  the  front  and  begin  passive  motion  of  the  knee-joint. 
At  the  end  of  six  weeks  cease  wearing  the  dressing  in  the 
da}-time,  and  at  the  end  of  three  months  discard  it  entirely. 
In  those  rather  unusual  cases,  in  which  an  oblique  fracture 
with  wide  separation  arises  from  direct  force,  treat  as  advised 
for  transverse  fracture  from  muscular  action.  The  question 
of  operation  is  practically  the  same  as  for  transverse  fracture 
from  muscular  action.  In  every  compound  fracture  of  the 
patella,  if  amputation  can  be  avoided,  incise,  irrigate  the  joint 
with  hot  saline  fluid,  suture  the  fragments,  and  drain  for 
twenty -four  to  forty-eight  hours. 

Ununited  and  Badly  United  Fracture  of  the  Patella. — 
There  is  usually  a  band  of  union,  but  it  ma\'  be  ver)-  thin 
and  the  fragments  ma\-  be  far  asunder.  It  is  usuall\-  taught 
that  the  degree  of  functional  impairment  depends  directly 
on  the  amount  of  separation.  This  is  not  strictly  true. 
There  may  be  great  separation,  and  but  little  impairment  of 
function,  the  fragments  being  firmly  united  with  a  dense 
fibrous  band.  There  may  be  little  separation  and  yet  lame- 
ness, stiffness  of  the  joint,  and  imperfect  power  of  extension. 
The  reason  of  this  has  been  pointed  out  by  Bruns  of 
Tubingen.^  He  says  there  may  be  complete  failure  of  union, 
even  when  the  separation  is  trivial,  and  failure  of  union  pro- 
duces impaired  function.  If  separation  is  considerable,  the 
fragments  are  apt  to  tilt  and  tissue  is  often  interposed 
between  them.  Functional  difficulty  is  more  often  met  with 
when  the  fragments  are  far  apart  than  when  the}'  are  near 
together,  because  non-union  is  more  common.  Even  if 
non-union  occurs,  in  some  cases  the  quadriceps  is  still  able 
to  act  upon  the  tibia  by  means  of  the  fascia  lata,  ligaments  at 
the  sides  of  the  joint,  or  bands  from  the  vasti  to  the  lower 
fragment.  Besides  non-union,  functional  impairment  may  be 
due  to  anchoring  of  the  upper  fragment  to  the  femur.  The 
upper  fragment  is  anchored  to  the  femur  by  the  interposition 
of  the  fibrous  investment  of  the  knee-cap,  which  covers 
the  fractured  surface  of  the  upper  fragment  and  grows  fast  to 
the  capsule  of  the  joint  (Bruns). 

The  treatment  of  ununited  and  badly  united  fracture  is  dis- 
cussed on  page  496. 

'  Beilrdge  zur  klinischen  Chiricrgie  Mittheihingen  aus  der  Chirttrg.  Klinik 
zur  Tubingen,  Bd.  3,  Heft  2,  1888. 


502    DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS. 

Fractures  of  the  Leg. — In  leg-fractures  both  bones  or 
only  one  bone  may  be  broken. 

Fractures  of  the  tibia  are  divided  into  (i)  fractures  of  the 
upper  end ;  (2)  separation  of  the  upper  epiphysis ;  (3)  fract- 
ures of  the  shaft;  (4)  fractures  of  the  lower  end;  and  (5) 
separation  of  the  lower  epiphysis. 

Fractures  of  the  upper  end  of  the  tibia  are  uncommon. 
They  may  be  transverse,  oblique,  or  vertical,  running  into  the 
joint.     The  cajise  is  direct  violence. 

Symptoms. — In  fracture  of  the  upper  end  of  the  tibia  there 
is  contusion  of  the  soft  parts.  In  a  transverse  fracture  there 
are  mobility  and  crepitus,  but  there  is  little  displacement.  In 
oblique  fracture  crepitus  and  mobility  are  marked,  the  axis  of 
the  limb  is  altered,  and  the  fragment  may  be  displaced.  In 
fractures  entering  the  joint  there  is  great  swelling  of  the 
knee-joint.  In  commimited  fractures,  which  exhibit  marked 
signs,  union  is  readily  obtained,  but  if  the  joint  has  been 
damaged  stiffness  is  sure  to  ensue. 

Treatment. — Reduce  displacement  by  extension  and 
manipulation.  The  special  apparatus  used  depends  on  the 
case.  In  some  cases  extension  is  required,  in  some  a 
posterior  splint  is  applied  and  the  limb  is  suspended  from  a 
gallows,  in  some  a  double  inclined  plane  is  employed,  and  in 
some  a  plaster-of-Paris  splint  is  used. 

The  double  inclined  plane  in  the  form  of  Mclntyre's  splint 
is  frequently  employed,  or  a  double  inclined  plane  in  the 
form  of  a  fracture-box  may  be  preferred.  The  extremity 
should  be  immobilized  for  four  weeks,  when  passive  motion 
should  be  begun.  Passive  motion  is  to  be  made  daily,  the  dress- 
ing being  reapplied  after  each  seance.  In  five  or  six  weeks  the 
dressings  are  removed  and  the  patient  allowed  to  go  about  on 
crutches.  The  crutches  are  soon  abandoned  for  a  cane,  and 
later  all  support  is  dispensed  with.  If  a  fracture  extends  into 
the  knee-joint  and  the  ill-adjusted  fragments  block  the  joint, 
the  joint  should  be  opened  and  the  fragments  placed  in 
proper  position. 

Separation  of  the  tubercle  of  the  tibia  is  due  to 
violent  contraction  of  the  quadriceps,  and  occurs  in  those 
under  twenty  years  of  age.  The  fragment  is  drawn  up 
and  can  be  felt,  and  the  patient  is  unable  to  use  the  limb. 
In  a  case  in  which  the  tibial  spine  has  been  torn  off,  the 
limb  should  be  placed  on  a  posterior  straight  splint  and 
the  fragment  should  be  pulled  down  into  place  by  adhe- 
sive strips  and  bandages.  The  splint  should  be  worn  for 
five  weeks. 


SPE  CIA  L    FRA  C  Ti  'A'ES. 


503 


Separation  of  the  Upper  Epiphysis  of  the  Tibia. — This 
is  an  injury  of  extreme  rarit}'.  It  does  not  seem  to  occur 
after  the  sixteenth  \-ear.  It  is  caused  b\'  a  twist  or  by 
violent  abduction  or  adduction  of  the  leg.  It  may  lead  to 
lessened  growth  of  the  limb.  The  treatvioit  is  as  for  a  fract- 
ure of  the  upper  end. 

Fractures  of  the  Shaft  of  the  Tibia. — The  causes  of  these 
fractures  are  direct  force,  indirect  force,  or  torsion.  The  fract- 
ure is  general!}"  transverse  in  the  upper  part  of  tlie  bone  and 
oblique  in  the  lower  part  ( Pickering  Pick). 

SvniptojHS. — In  transverse  fracture  of  the  shaft  of  the  tibia 
there  is  no  deformity,  and  the  support  of  the  tibula  may  e\en 
permit  of  walking :  there  is  fixed  pain :  there  may  or  may 
not  be  inequalit}-  of  the  fragments  felt  b\-  the  finger ;  and  there 
are  crepitus,  mobilit}*,  and  often  linear  ecchymosis.  In  oblique 
fractures  there  usually  exist  crepitus,  a  little  mobility,  and 
distinct  deformit}-.  The  deformity  depends  on  the  direction 
of  the  line  of  fracture,  and,  as  this  line  is  usually  from  above 
downward,  inward,  and  a  little  forward,  the  lower  fragment 
usually  passes  behind  the  upper  fragment  and  rotates  inward. 

Treatment. — In  treating  fractures  of  the  shaft  of  the  tibia, 
effect  reduction  b\"  making  extension  from  foot  and  coun- 
ter-extension from  the  knee,  the  knee  being  in  partial  flex- 
ion.    If  there  be  much  swelling,  put  the  limb  in  a  fracture- 


(T^ 


^ifeA^  mm- 

Fig.  163. — Fracture-box  in  fractures  of  the  bones  of  the  leg. 


box  (PL  6,  Fig.  I  ;  Fig.  163),  swing  the  box  from  a  gallows, 
and  apply  an  ice-bag  for  a  day  or  two.  A  silicate-of-sodium 
or  a  plaster-of- Paris  dressing  is  applied  when  the  swelling 
subsides,  or  the  dressing  is  used  at  once  if  swelling  is  slight. 
As  soon  as  the  limb  is  immobilized  in  a  silicate  or  plaster 
dressing  the  patient  gets  about  on  crutches.    The  dressing  is 


504   DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS. 

removed  after  five  weeks,  and  the  patient  goes  about  for  one 
week  on  crutches,  hghtly  using  the  foot,  and  then  for  a  time 
with  a  cane.  At  the  end  of  eight  or  nine  weeks  the  cane  may 
often  be  dispensed  with,  the  amount  of  use  of  the  leg  being 
daily  augmented. 

Fractures  of  the  Lo"wer  End  of  the  Tibia :  Fracture 
of  the  Inner  Malleolus. — The  cause  of  fracture  of  the  inner 
malleolus  is  direct  force  or  traction  upon  the  internal  lateral 
ligament. 

Symptoms  and  Treatment. — The  symptoms  of  fracture  of 
the  inner  malleolus  are  some  downward  displacement,  de- 
pression above  the  fragment,  mobility,  and  crepitus.  The 
treatment  is  to  push  the  fragment  into  place  and  use  side- 
splints  or  a  fracture-box  for  two  weeks,  when  a  plaster-of- 
Paris  or  a  silicate  dressing  may  be  substituted  and  the  pa- 
tient be  ordered  to  use  crutches.  Remove  the  plaster  four 
or  five  weeks  after  it  is  applied,  and  direct  the  patient  to 
gradually  bear  his  weight  upon  the  leg,  as  outlined  above. 

Separation  of  the  lower  epiphysis  of  the  tibia  is  a  rare 
accident,  but  is  commoner  than  separation  of  the  upper,  epiph- 
ysis.    The  treatment  is  a  fixed  dressing  for  six  weeks. 

Fracture  of  the  fibula  alone  is  commoner  by  far  than  is 
fracture  of  the  tibia  alone.  Fractures  in  the  upper  two-thirds, 
which  are  rare,  are  usually  due  to  direct  force.  Fractures  in 
the  lower  third  are  frequent,  and  they  arise  from  indirect  force. 

Fractures  of  the  Upper  Two-thirds  of  the  Fibula. — In 
these  fractures  the  canse  is  direct  force. 

Symptoms. — In  fracture  of  the  upper  two-thirds  of  the 
fibula  the  patient  can  often  walk.  The  bone  is  deeply  situ- 
ated, and  displacement  cannot  often  be  detected.  There  is 
a  fixed  pain,  which  is  intensified  by  movement  and  by  press- 
ure. Pressure  upon  the  lower  fragment  does  not  move  the 
upper  fragment.  Crepitus  is  sometimes  obtained,  and  a  linear 
ecchymosis  is  apt  to  appear.  The  bone  is  normally  elastic, 
hence  slight  mobility  is  of  no  value  diagnostically. 

Treatment. — In  treating  a  fracture  of  the  upper  two-thirds 
of  the  fibula  apply  a  plaster-of-Paris  or  a  silicate  bandage 
and  direct  that  it  be  worn  for  five  weeks.  Weight  is  not  to 
be  put  upon  the  foot  for  six  weeks  after  the  accident. 

Fractures  of  the  Lower  Third  of  the  Fibula. — In  these 
fractures  the  cause  is  indirect  force,  especially  twists  of  the 
foot.  Forcible  inversion  of  the  foot  pulls  upon  the  external 
lateral  ligament  and  the  external  malleolus,  forces  the  fibula 
outward,  and  tends  to  break  it,  the  lower  fragment  beine  dis- 
placed  outward.     Forcible  eversion  pulls  the  internal  lateral 


SPECIAL   FRACTURES.  505 

lio-ament  off  from  the  inner  malleolus  (often  breaks  the  mal- 
leolus) and  fractures  the  fibula  above  the  ankle,  the  bone 
being  displaced  inward. 

Pott's  fracture. — B>-  the  name  Pott's  fracture  is  meant  a 
fracture  of  the  lower  fifth  of  the  fibula  produced  by  eversion 
and  abduction  of  the  foot.     Stimson  points  out  that  the  pro- 
duction of  Pott's  fracture  is  often  aided  by  the  weight  of  the 
bod\-.     The  lesions  which  arise  depend  upon  whether  the 
chief  force  is  eversion  or  abduction.     "  M"  eversion  is  the  sole, 
or  main,  movement,  the  force  is  exerted  through  the  internal 
lateral  ligament  and  breaks  the  internal  malleolus  squarely 
off  at  its  base  ;  then  it  presses  the  external  malleolus  outward, 
rupturing  the  tibiofibular    ligament,  and    breaks    the    fibula 
close  above  the  malleolus.     Sometimes  instead  of  pure  rupt- 
ure of  the  tibiofibular  ligament  there  is  avulsion  of  the  por- 
tion of  the  tibia  to  which  it  is  attached."  ^     Stimson  further 
points  out  that  if  abduction  is  the  preponderating  force  there 
is  an  oblique  fracture  of  the  anterior  portion  of  the  internal 
malleolus  or  more  frequently  rupture  of  the  anterior  portion 
of  the  internal  lateral  ligament.    There  is,  as  in  the  former  case, 
rupture  of  the  tibiofibular  ligament  and  an  oblique  fracture 
of  the    fibula    several  inches  above  the  external  malleolus. 
It  is  evident  that  the  degree  of  injury  produced  by  eversion 
and  abduction  depends  on  the  time  at  which  the  force  is  ar- 
rested.    It  may  be  arrested  after  the  inner  malleolus  has  been 
separated  or  the  anterior  fibres  of  the  deltoid  Hgament  torn, 
and  in  this  case  the  tibiofibular  articulation   remains  intact 
and  the  fibula  is   not  broken.     It  may  cease  after  separating 
the  tibiofibular  articulation,  and  in  this  case  too  the  fibula 
escapes.     It  may  be  continued  until  the  fibula  breaks.     In 
this  fracture  the' astragal  us  passes  outward,  somewhat  back- 
ward and  also  upward,  the  later  deviation  being  due  to  separa- 
tion of  the  tibiofibular  articulation. 

Symptoms.— T\\&  foot  is  displaced  outward,  and  a  little 
backward  and  upward,  and  the  inner  malleolus  or  the  tibia 
from  which  it  was  torn,  is  extremely  prominent.  There  is 
cTi-eat  lateral  mobilit\^  and  often  anteroposterior  mobilit}^  at  the 
ankle-joint.  Stimson  points  out  that  there  are  three  points 
where  pressure  is  certain  to  provoke  pain  :  in  front  of  the 
tibiofibular  ligament,  at  the  base  or  anterior  border  of  the 
inner  malleolus,  and  over  the  seat  of  fracture  through  the  fibula. 
7;T^z/;;/r;//.— Thorough  reduction  is  of  the  greatest  impor- 
tance. If  thorough  reduction  is  effected,  a  good  result  will  prob- 
ably be  obtained  ;  but  if  thorough  reduction  is  not  effected  the 

1  A  Practical  Treatise  on  Fractures  and  Dislocations,  by  Lewis  A.  Stimson. 


5o6   DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS. 

patient  will  be  permanently  crippled  to  a  greater  or  less  ex- 
tent. In  order  to  effect  reduction  it  may  be  necessary  to  an- 
esthetize the  patient.  The  deformity  is  corrected  "  by  press- 
ing the  calcaneum  forward  and  inward ;  the  hand  is  placed 
against  the  back  and  outer  side  of  the  heel  and  pressed  for- 
ward and  then  forcibly  inward."  ^ 

Some  surgeons  at  once  surround  the  limb  with  a  plaster- 
of-Paris  bandage.  This  treatment  is  objectionable  because 
the  deformity  may  be  practically  reproduced,  the  surgeon 
being  unable  to  see  it,  and  hence  unable  to  correct  it.  If 
there  seems  to  be  no  strong  tendency  to  a  recurrence  of 
deformity,  a  fracture-box  can  be  used. 

After  reducing  displacement,  place  the  limb  in  a  fracture- 
box  containing  a  soft  pillow.  A  bird's-nest  pad  of  cotton 
or  oakum  is  made  for  the  heel  (Fig.  163).  A  fillet 
around  the  ankle  fastens  the  foot  to  the  foot-piece  of  the 
box ;  a  pad  of  oakum  rests  between  the  foot-piece  and  the 
sole.  A  compress  is  placed  below  the  outer  malleolus  and 
another  one  above  the  inner  malleolus.  Close  the  sides  of 
the  box  and  tie  them  together  with  a  bandage,  and  swing  the 
box  on  a  gallows.  Every  day  let  down  the  sides  of  the  box 
and  rub  the  leg,  the  ankle,  and  the  foot  with  alcohol.  In 
ten  days  apply  a  plaster-of- Paris  bandage  and  let  the  patient 
get  about  on  crutches.  Remove  the  plaster  at  the  end  of 
the  fifth  week  after  the  accident,  and  let  the  patient  go  about 
with  crutches  for  one  week  and  with  a  cane  for  a  week  longer. 

Some  surgeons  dress  Pott's  fracture  with  a  Dupuytren 
splint.  This  is  a  straight  splint  (PI.  6,  Fig.  9)  which  reaches 
from  the  head  of  the  tibia  to  or  below  the  toes.  This  splint 
is  padded,  and  a  pyramidal  pad  with  the  base  down  is  laid 
upon  the  inner  surface  of  the  leg,  above  the  inner  malleolus, 
the  splint  being  put  upon  the  inner  surface  of  the  leg,  over 
the  pad.  The  splint  is  fastened  as  shown  in  Plate  6  (Fig.  9), 
and  the  leg  is  semiflexed  upon  the  thigh  and  is  laid  upon  its 
outer  surface  on  a  pillow.  After  ten  days  apply  the  plaster-of- 
Paris  bandage,  which  is  to  be  worn  as  above  directed.  Bryant 
treats  Pott's  fracture  with  a  posterior  splint,  two  lateral 
splints,  and  a  swing.  Stimson  uses  a  posterior  and  lateral 
splint  of  plaster  of  Paris.  This  splint  does  not  slip,  as  may 
Dupuytren's  dressing,  and  does  not  hide  the  seat  of  fracture 
from  view  as  does  complete  encasement  with  plaster  of  Paris. 
It  is  a  most  useful  dressing.  The  fracture  may  be  compound, 
a  portion  of  the  inner  malleolus  or  of  the  tibia  projecting 
through   the  wound.    If  it  is  necessary  to  introduce  through 

^  Stimson's  Practical  Treatise  on  Fractures  and  Dislocations. 


SPE  CIA  L    FRA  CTL  'RES.  5  0/ 

and  through  drainage,  the  foot  must  be  placed  and  kept 
at  a  right  angle  to  the  leg.  If  a  compound  fracture  exists, 
it  may  be  possible  to  wire  the  malleolus  in  place.  In 
a  reported  case  the  wire  was  passed  through  the  joint  and 
around  the  fragment,  and  the  result  was  good.*  It  would 
be  better  to  nail  the  fragment  in    place. 

Fracture  of  both  bones  of  the  leg  is  a  very  common 
injury,  is  often  compound,  and  is  not  unusually  comminuted. 
Fractures  by  direct  force,  such  as  blows  or  kicks,  are  com- 
monest in  the  upper  half  of  the  leg.  Fractures  by  indirect 
force,  as  by  falls,  are  commonest  in  the  lower  half  of  the  leg. 
In  fractures  from  indirect  force  the  tibia  breaks  first,  and 
then  the  fibula  breaks  at  a  higher  level.  The  point  of 
greatest  liability  to  fracture  from  indirect  force  is  the  junc- 
tion of  the  lower  and  middle  thirds.  Fractures  of  the  leg 
are  usually  oblique,  but  they  may  be  transverse  if  arising 
from  direct  force.  Spiral,  torsion,  or  V-shaped  fractures  and 
longitudinal  breaks  sometimes  occur.  In  oblique  fractures, 
as  a  rule,  the  line  of  fracture  runs  downward,  inward,  and  a 
little  forward. 

Symptoms. — Fracture  of  both  bones  of  the  leg  is  easy  of 
recognition.  The  fibular  fracture  is  detected  as  before  de- 
scribed. By  running  the  finger  along  the  crest  of  the  tibia 
displacement  will  be  found,  except  in  transverse  fractures, 
when  it  may  not  occur.  The  common  displacement  is  for 
the  lower  fragment  to  ascend  and  pass  behind  the  lower  end 
of  the  upper  fragment  and  to  rotate  a  little  outward,  and 
for  the  upper  fragment  to  project  in  front.  The  ascent  of 
the  lower  fragment  is  due  to  the  action  of  the  gastrocnemius 
and  soleus  muscles.  If  the  line  of  fracture  is  in  a  direc- 
tion the  reverse  of  that  which  is  usual,  the  lower  fragment 
ascends  in  front  of  the  lower  end  of  the  upper  fragment.  In 
fracture  of  both  bones  of  the  leg  there  are  marked  mobility 
and  crepitus,  severe  pain,  and  inability  to  walk.  In  fractures 
from  direct  force  there  is  more  or  less  damage  to  the  soft 
parts.  A  fracture  of  the  shaft  of  the  tibia  near  the  ankle  is 
distinguished  from  a  dislocation  by  the  fact  that  the  deformity 
is  easily  reduced,  but  tends  to  recur  in  the  fracture,  and, 
further,  that  in  a  fracture  the  relations  of  the  malleoli  to  the 
tarsus  are  unaltered,  whereas  in  a  dislocation  they  are  altered. 

Treatment. — If  the  fracture  is  near  the  ankle-joint,  the 
action  of  the  tendo  Achillis  may  maintain  deformity,  and  in 
such  cases  the  tendon  must  be  divided.  In  treating  a  simple 
fracture  of  the  lower  two-thirds  of  the  bones   reduce  b>'  ex- 

1  Rev.   de  Chir.,  vol.  viii.,   lS88. 


5o8   DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS. 

tension  and  counter-extension,  and  use  a  fracture-box  (PI.  6, 
Fig.  I )  as  in  Pott's  fracture  (p.  506),  though  the  compresses 
are  not  required.  If  the  soft  parts  are  bruised,  use  an  ice- 
bag  for  a  day  or  two ;  if  they  are  abraded,  apply  antiseptic 
dressings.  The  fracture-box  should  be  swung  upon  a 
gallows.  After  three  weeks  apply  plaster-of-Paris  or  silicate- 
of-sodium  dressing  and  let  the  patient  sit  up  in  a  chair  daily 
for  one  week  ;  at  the  end  of  this  time  the  patient  may  get 
about  with  crutches.  At  the  end  of  six  weeks  after  the 
accident  remove  the  plaster,  and  let  the  sufferer  get  about 
on  crutches  for  two  weeks  and  with  a  cane  for  two  weeks 
more.  Brinton  dresses  a  fracture  of  both  bones  of  the  leg 
for  two  weeks  in  a  fracture-box,  for  two  weeks  in  side-splints 
made  of  metal,  and  for  two  weeks  in  an  immovable  dressing, 
allowing  the  patient  to  get  about  on  crutches  as  soon  as  the 
plaster  is  put  on.  Instead  of  the  fracture-box,  we  may  use  a 
posterior  splint,  two  lateral  splints,  and  a  swing.  Nathan  R. 
Smith's  anterior  splint  is  used  by  some  in  the  treatment  of 
fractures  of  the  leg.  Many  surgeons  apply  plaster  of  Paris 
in  the  form  of  an  ambulatory  dressing.  In  this  dressing  a 
solid  apparatus  reaches  to  the  lower  third  of  the  thigh  and 
below  the  sole  of  the  foot.  When  the  patient  Avalks  the 
weight  is  transmitted  to  the  thigh  (Fig.  166).  In  fractures 
of  the  upper  third  of  the  leg  the  Mclntyre  splint  or  the 
double  inclined  plane  is  used.  If  the  fracture  is  compound, 
asepticize  thoroughly,  make  a  counter-opening,  insert  a 
drainage-tube,  dress  with  bichlorid  gauze,  apply  a  plaster 
bandage,  and  cut  trap-doors  over  the  openings  of  the  tube 
(see  Fig.  1 14),  or  dress  Avith  the  bracketed  splint  and  plaster 
of  Paris  (Fig.  115).  Remove  the  tube,  as  a  rule,  in  about 
forty-eight  hours ;  but  the  patient's  temperature  is  a  better 
guide  than  time. 

Fractures  of  the  bones  of  the  foot  are  rather  rare  acci- 
dents. Owing  to  the  number  of  the  bones  and  to  the 
elasticity  of  their  connections,  the  force  of  blows  and  falls 
is  spread  and  dissipated.  Fractures  from  direct  force  are 
often  compound.  The  cause  of  fracture  of  either  the  scaph- 
oid, the  cuboid,  or  one  of  the  cuneiform  bones  is  direct 
force.  Fractures  of  the  os  calcis  and  astragalus  arise,  as 
a  rule,  from  indirect  force,  such  as  falls,  but  the  calcaneum 
may  be  broken  by  direct  violence.  In  rare  instances  the 
OS  calcis  has  been  broken  by  contraction  of  the  great  calf- 
muscles. 

Symptoms. — In  fracture  of  the  os  calcis  there  are  severe 
pain,  swelling,  crepitus,  mobility,  often  an  apparent  widening 


SPECIAL    I-KACTL'KES.  509 

of  the  bone,  not  unusually  a  loss  of  the  arch  of  the  foot 
(Pick).  In  some  cases  the  posterior  fragment  is  drawn  up 
by  the  calf-muscles,  and  in  other  cases  there  is  deformit>-. 
In  fracture  of  the  astragalus  displacement  may  occur  w  hicli 
resembles  that  of  a  dislocation.  Crepitus  may  or  may  not 
be  detected.  It  can  be  elicited,  as  a  rule,  by  rotating  the 
foot  while  the  heel  is  firmly  held.  If  crepitus  cannot  be 
detected,  it  is  not  certain  that  a  fracture  is  present,  though 
the  patient  ma\'  be  unable  to  stand  and  there  may  be  swell- 
ing and  pain  on  pressure.  Fractures  of  the  other  bones  are 
difficult  of  detection.  There  may  or  may  not  be  crepitus, 
which,  if  it  exists,  is  hard  to  localize  ;  there  is  pain  on  stand- 
ing and  on  pressure,  and  there  is  bruising  of  the  soft  parts. 

Treatment. — To  treat  a  fracture  of  the  os  calcis  when  no 
deformity  exists,  use  a  fracture-box  for  two  weeks,  maintain- 
ing the  foot  at  a  right  angle  to  the  leg ;  then  put  on  an 
immovable  dressing,  and  let  it  be  worn  for  four  \\eeks. 
In  fracture  of  the  os  calcis  with  drawing  up  of  the  posterior 
fragment  flex  the  leg  upon  the  thigh,  extend  the  foot,  and 
maintain  this  position  by  means  of  a  band  around  the 
thigh,  the  band  being  fastened  by  means  of  a  cord  to  a 
slipper  (PI.  7,  Fig.  5),  the  leg  resting  upon  its  outer  side. 
At  the  end  of  two  weeks  apply  plaster  of  Paris,  and  let 
it  be  worn  for  four  weeks.  ^lany  cases  require  incision 
and  nailing  or  wiring  the  fragments  together.  If  the  pro- 
jecting fragment  of  the  os  calcis  cannot  be  forced  into 
place,  and  if  it  makes  dangerous  pressure  upon  the  skin, 
excise  it ;  if  it  does  not  make  pressure  which  threatens 
sloughing,  place  the  joint  in  a  position  favorable  for  anky- 
losis, and  immobilize.  In  a  fracture  of  the  astragalus  use  a 
fracture-box  and  then  an  immo\'able  dressing,  as  in  fracture 
of  the  os  calcis  without  deformity.  Fractures  of  the  other 
bones  of  the  tarsus  are  almost  invariabh'  compound,  and  the 
injury  may  require  drainage  and  immovable  dressing,  excis- 
ion of  bones,  or  even  amputation. 

Fractures  of  the  metatarsal  bones  are  due  to  direct 
force  and  are  almost  always  compound.  Fractures  from 
crushes  usually  demand  e.xcision  or  amputation.  \Mien 
only  one  bone  is  broken  displacement  is  slight,  there  is 
severe  pain  on  motion  and  pressure,  and  crepitus  can  gener- 
ally be  obtained.  A  simple  fracture  of  a  metatarsal  bone 
is  treated  by  an  immovable  dressing  for  four  weeks. 

Fractures  of  the  phalanges  of  the  toes  are  due  to  direct 
force  and  are  often  compound.  The\'  may  require  imme- 
diate amputation. 


5IO   DISEASES  AND    INJURIES    OF  BONES  AND  JOINTS. 

Trcaii/icnt. — In  a  compound  fracture  where  amputation  is 
unnecessary,  drain  with  strands  of  catgut  for  forty-eight 
hours  and  dress  antiseptically ;  at  the  end  of  this  time  apply 
over  the  bichlorid  gauze  a  gutta-percha  or  a  pasteboard 
splint  extending  from  beyond  the  end  of  the  toe  to  well  up 
upon  the  sole  of  the  foot,  and  fix  the  splint  in  place  with  a 
spiral  bandage  of  the  toe  and  instep.  The  splint  is  to  be 
worn  for  four  weeks.  In  a  simple  fracture  fasten  the  injured 
toe  to  an  adjacent  toe  or  toes  by  a  plaster  bandage  and 
wear  the  dressing  for  three  weeks. 


3.  Diseases  of  the  Joints. 

Synovitis  is  a  primary  inflammation  of  the  synovial  mem- 
brane alone.  If  other  structures  besides  the  synovial  mem- 
brane are  involved,  the  condition  is  known  as  "  arthritis." 
Two  forms  of  simple  synovitis  exist — namely,  acute  and 
chronic.     Some  surgeons  speak  also  of  subacute  cases. 

Acute  Simple  Synovitis. — The  causes  of  acute  simple 
synovitis  are  contusions,  sprains,  twists,  and  overuse,  The 
causative  influence  of  exposure  to  cold  or  damp  has  been 
much  debated.  It  seems  probable  that  in  some  cases  cold 
produces  vasomotor  paresis  of  the  vessels  of  the  synovial 
membrane,  a  condition  which  may  be  followed  by  inflamma- 
tion. In  synovitis  the  membrane  is  red  and  swollen,  and  the 
joint  contains  an  excess  of  turbid  fibrinous  fluid.  If  the  in- 
flammation advances,  arthritis  arises  and  sometimes  blood  is 
effused. 

Symptoms. — The  symptoms  of  acute  synovitis  are — pain, 
which  is  increased  by  motion  of  the  joint,  by  pressure  upon 
the  articulation,  and  by  a  dependent  position  of  the  limb, 
which  is  worse  at  night.  Pressure  upon  the  cartilage 
does  not  cause  pain,  but  friction  of  the  synovial  membrane 
at  once  develops  it.  The  patient  places  the  limb  in  the 
position  which  gives  the  greatest  ease,  and  in  this  position 
the  part  becomes  more  or  less  fixed  as  the  muscles  about  the 
joint  are  rigid.  A  fluctuating  swelling  is  noted  in  a  super- 
ficial joint,  most  marked  between  the  ligaments,  which 
swelling  bulges  out  the  synovial  area  and  hides  or  obscures 
the  articular  heads  of  the  bones.  The  swelling  is  due  early  to 
extensive  secretion  of  synovia,  and  later  to  effusion  of  liquor 
sanguinis.  Bulging  takes  place  at  points  w^here  the  capsule  is 
thin,  and  at  such  points  fluctuation  may  be  detected.  Fluc- 
tuation in  the  elbow  is  sought  for  posteriorly.  Fluctuation  in 
the  knee  is  sought  for  on  either  side  in  front.     A  large  effu- 


SYiVOVIT/S.  511 

sion  in  the  knee  floats  the  patella  up  from  the  condyles.  A 
small  effusion  in  the  knee  can  be  detected  by  Fiske's  plan, 
which  is  as  follows  :  Tell  the  patient  to  bend  forward  at  the 
hips,  resting  each  hand  on  the  front  of  the  corresponding 
thigii.  The  anterior  structures  of  the  joint  are  relaxed,  and, 
by  tapping  the  patella,  even  a  small  effusion  can  be  discovered. 
Bulging  cannot  be  distinctly  observed  in  the  hip  or  shoulder, 
unlc^ss  effusion  is  great.  The  skin  over  the  joint  is  rarely 
reddened,  but  feels  hot  to  the  hand  of  the  observer  (over 
more  superficial  joints,  but  not  over  shoulder  and  hip) ;  the 
joint  is  partly  flexed  ;  fever  exists,  varying  in  degree  with  the 
size  of  the  joint,  the  acuteness  of  the  attack,  and  the  nature 
of  the  cause.  Suppuration  rarely  follows  simple  synovitis, 
but  it  may  do  so,  the  area  of  synovitis  being  a  point  of  least 
resistance  to  organisms  in  the  blood  or  lymph.  If  suppura- 
tion takes  place  rigors  occur,  there  is  a  septic  temperature, 
and  the  joint  soon  gives  evidence  of  containing  pus.  These 
evidences  are  violent  pain,  increased  tenderness,  dusky  dis- 
coloration if  the  joint  be  superficial,  greater  muscular  spasm, 
periarticular  edema,  and  constitutional  symptoms  of  sepsis. 
Traumatic  synovitis  without  infection  tends  toward  cure 
without  suppuration  if  the  patient  is  healthy,  and  after  it 
ankylosis  is  rare. 

rrcatmcnt.— In  treating  acute  synovitis  mimobilize  the 
joint.  In  severe  cases  place  it  in  such  a  position  that  the 
hmb  will  still  be  useful  even  if  ankylosis  occurs.  In  mild 
cases  immobilize  in  the  position  of  rest,  apply  leeches,  and 
use  the  ice-bag  or  the  Leiter  coil.  After  a  day  or  two  apply 
gentle  pressure,  intermittent  heat,  and  iodin  and  ichthyol. 
If  the  effusion  is  very  great  and  persistent,  and  pressure, 
heat,  and  sorbefacients  fail  to  remove  it,  aspirate  with  anti- 
septic care.  If  effusion  recurs  after  respiration,  apply  a 
plaster-of-Paris  dressing  or  use  flying  blisters  and  massage. 
A  rubber  bandage  is  often  useful  toward  the  termination  of 

a  case.  .  •      r  ,, 

Chronic  Sjmovitis.— Chronic  synovitis  follows  acute 
synovitis  or  it  may  be  chronic  from  the  start.  Many  cases 
called  chronic  synovitis  are  in  truth  tubercular  disease.  The 
synovial  membrane  looks  nearly  natural,  but  is  edematous, 
and  the  joint  contains  an  excess  of  fluid.  If  the  quantity 
of  fluid  is  large,  the  disease  is  called  "  hydrops  articuli,"  or 
"dropsy"  A  large  amount  of  fluid  in  the  knee-joint 
"  floats  "  the  patella  upward.  Tubercular  infection  is  apt  to 
occur  in  very  prolonged  cases.  In  prolonged  chronic  syno- 
vitis the  synovial  membrane  thickens  in  some  places,  softens 


512    DISEASES  A  AW   INJURIES    OF  BONES  AND  JOINTS. 

in  Others,  is  often  adherent,  and  the  villous  processes  of 
the  synovial  membrane  hypertrophy.  If  the  membrane 
becomes  extensively  softened  (pulpy  degeneration),  the  soft- 
ened areas  bulge  and  caseation  eventually  occurs.  In  the 
knee-joint  a  traumatic  synovitis  is  sometimes  linked  with 
inflammation  of  the  semilunar  cartilages.  Roux  tells  us  that 
this  inflammation  may  be  produced  by  a  squeeze,  a  twist, 
or  a  direct  force,  but  a  squeeze  is  the  common  cause.  Hy- 
perextension  of  the  knee  may  squeeze  the  cartilage,  and  so 
may  attempting  to  rise  from  a  stooping  posture.^  If  this 
injury  has  taken  place,  the  disability  will  be  prolonged. 

Symptoms. — In  chronic  synovitis  pain  is  absent  or  is  only 
present  during  exercise  or  from  pressure,  and  is  slight  even 
then  ;  there  is  some  Hmitation  of  movement;  passive  motion 
may  develop  creaking  or  joint-crepitus ;  fluctuation  is  ap- 
parent; there  is  atrophy  in  the  muscles  about  the  joint; 
and  the  hypodermatic  needle  will  draw  out  a  viscid,  straw- 
colored  or  bloody  fluid. 

Treatment. — For  hydrops  use  rest  and  pressure.  Pressure 
may  be  obtained  by  the  application  of  Martin's  rubber 
bandage.  A  plaster-of-Paris  dressing  is  probably  the  best 
way  to  combine  rest  and  compression.  Massage,  douches, 
frictions,  passive  movements,  and  flying  blisters  should  be 
used.  Painting  the  joint  with  iodin  and  spreading  over  it 
blue  ointment,  and  rubbing  in  ointment  of  ichthyol  (50  per 
cent,  with  lanolin)  may  do  good.  Counter-irritation  by  the 
actual  cautery  is  a  valuable  expedient.  Aspiration  and  the 
subsequent  use  of  a  plaster-of-Paris  bandage  may  be  tried 
in  some  cases.  Some  surgeons  advise  aspiration,  washing 
out  with  salt  solution,  injecting  a  5  per  cent,  solution  of 
carbolic  acid,  and  immobilizing.  Incision  and  drainage 
constitute  a  radical  but  proper  plan,  in  cases  unamended 
by  simpler  methods.  If  pulpy  degeneration  exists,  perform 
an  excision  or  an  erasion.  If  pus  forms,  incise  at  once 
and  drain.  Internally,  treat  any  existing  diathesis  and  give 
nutritious  food,  tonics,  and  stimulants.  Chronic  synovitis 
is  often  greatly  benefited  by  the  use  of  a  hot-air  appa- 
ratus. The  limb  is  wrapped  in  flannel  and  is  placed  in 
an  oven.  The  oven  is  heated  by  Bunsen  burners.  The 
temperature  is  raised  to  about  300°  F.,  and  the  limb  is 
subjected  to  this  for  one  hour.  The  oven  should  be  used 
daily,  and  as  the  patient  becomes  accustomed  to  it  even  a 
higher  degree  of  heat  can  be  tolerated.  This  high  degree 
of  heat  can   be  borne  only  when  it  is  perfectly  dry.     Any 

*  Gaz.  des  Hop.,  No.   125,  1895. 


ARTHRJTIS. 


513 


moisture  scalds  the  patient.  The  Lentz  oven  has  in  it  ven- 
tihition  openings  to  get  rid  of  moisture  and  tlie  sweat  is 
taken  up  by  the  flannel.  This  flannel  must  not  be  applied 
so  thickly  as  to  keep  the  heat  notably  from  the  joint  nor 
must  so  little  of  it  be  used  as  to  permit  of  its  soaking  with 
sweat.  Fig.  164  shows  the  Sprague  hot  dry-air  apparatus, 
and  Fig.  165  exhibits  a  cross-section  of  the  same  apparatus. 
Dr.   H.  A.  Wilson  inserts  in  the  oven  humidin,  a  product 


Fig.  164. — Sprague  hot  dry- air  apparatus. 


obtained  in  the  purification  of  salt,  which  material  entirely  ab- 
sorbs moisture.  Cotton  should  not  be  used  to  wrap  the  limb, 
because,  if  the  bottom  of  the  oven  becomes  red-hot,  the  cotton 
may  ignite  and  burn  the  patient.  A  physician  or  nurse  should 
constantly  watch  the  apparatus  during  its  employment.^ 

Arthritis. — By  this  term  is  meant  not  only  inflammation 
of  a  synovial  membrane,  but  also  of  other  structures  com- 
posing and  surrounding  a  joint.     It  may  follow  a  traumatic 

^  H.  A.  Wilson,  m  Annals  of  Surgery,  I'eb.,  1S99. 
33 


514   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

synovitis ;  it  may  be  due  to  pus  organisms,  to  tubercle 
bacilli,  to  infectious  diseases  (gonorrhea  and  typhoid  fever), 
to  rheumatism,  to  gout,  to  syphilis,  and  to  lesions  of  the 
spinal  cord.     Arthritis  may  be  either  acute  or  chronic. 

Tubercular  Arthritis  (White  Swelling ;  Strumous  Joint ; 
Pulpy  Degeneration). — PatJiology  and  Symptoms. — The  pre- 
disposing causes  of  tubercular  arthritis  may  be  strains, 
blows,  twists,  or  cold.  The  real  cause  is  the  bacillus  of 
tubercle.  The  primary  infection  with  tubercle  bacilli  is 
usually  in  the  bone,  though  it  may  be  in  the  synovial  mem- 


FiG.  165. — Cross-section  of  Sprague  >iot  dry-air  apparatus  :  A,  A,  air  intakes  ;  b,  circulat- 
ing air  space  ;  E.  jacketed  space  for  products  of  combustion  ;  g,  treatment-chamber  ;  M,  M, 
cork  ribs;  N,  N,  perforations  admitting  heated  air;  o,  base  holding  apparatus;  P,  P,  gas- 
burners. 


brane,  the  joint-capsule,  or  the  structures  about  the  joint. 
If  the  primary  infective  focus  is  in  the  bone,  and  it  usually 
is,  a  portion  of  the  cartilage  is  destroyed  and  the  joint  is 
opened,  or  a  sinus  forms  and  perforates  the  synovial  mem- 
brane. When  tubercular  inflammation  attacks  the  synovial 
membrane  granulation-tissue  is  formed,  and  the  capsule  and 
periarticular  structures  soon  become  involved  in  the  process; 
the  parts  thicken  and  soften  from  caseation,  and  they  may 
be  covered  with  tubercles,  though  but  little  fluid  is   usually 


AKTiiRiris.  5  Id 

eft  used  into  the  joint.  Some  few  cases  present  large  joint- 
effusions.  In  the  ordinary  form  of  arthritis  there  occurs 
what  is  known  as  " gelatin iform  degeneration;"  the  granula- 
tion-tissue is  formed  in  large  amount  as  fungous  growths: 
the  structures  are  markedly  edematous  and  softened ;  the 
relaxed  hgaments  }-ield  under  pressure ;  the  natural  contour 
of  the  joint  is  lost,  and  it  becomes  spindle-shaped;  all  the 
structures,  articular  and  periarticular,  are  glued  into  one 
mass ;  the  skin  about  the  joint  is  white,  thick,  and  adher- 
ent, and  in  it  one  or  more  large  veins  are  seen ;  fluctuation 
or  pseudofluctuation  is  noted  when  caseation  has  occurred ; 
pain  is  not  often  severe,  but  it  can  usually  be  elicited  by 
certain  motions  or  by  firm  pressure,  but  the  pain  will  always 
be  severe  when  the 'epiphysis  is  involved;  the  temperature 
of  the  part  is  somewhat  elevated ;  deformity  results  from 
destruction  of  bone,  cartilage,  and  ligament,  from  muscular 
spasms,  and  from  the  habitual  assumption  of  certain  atti- 
tudes to  secure  rehef  from  pain.  There  is  soon  impairment 
of  joint-motions.  When  the  products  of  a  tubercular 
arthritis  caseate,  the  thick  liquid  seeks  exit  by  forming 
sinuses  from  which  caseous  pus  flows.  If  a  sinus  becomes 
infected  with  pyogenic  cocci,  and  the  joint  itself  becomes 
their  prey,  acute  suppuration  arises  in  the  joint,  andconsti- 
tutional  involvement  is  pronounced  and  perilous  to  lite. 

In  pannous  synovitis  a  large  effusion  is  formed,  there  is 
but  little  granulation-tissue,  though  the  tubercles  are  pres- 
ent in  larcxe  numbers,  and  the  ligaments  and  structures  about 
the  joint  are  slightlv  or  not  at  all  implicated.  The  diagnosis 
early  in  a  tubercular  joint  is  often  difficult,  and  sometimes 
impossible,  and  the  prognosis  is  always  grave.  In  only  a 
very  few  cases,  even  when  recognized  early,  is  a  cure  obtained 
Avitiiout  some  impairment  of  ioint-function.  The  best  that 
can  usuallv  be  accomplished  is  a  cure  with  more  or  less 
ankylosis,  fibrous  or  bonv ;  and  often  ankylosis  is  complete. 
Lon<T  after  the  disease  is  apparently  cured,  it  may  break 
fortlf  anew.  Tubercular  lesions  may  arise  in  a  distant  organ, 
or  creneral  tuberculosis  may  occur.  Caseation  is  apt  to 
produce  severe  constitutional  disorder.  Infection  bv  pus 
organisms  gives  rise  to  grave  danger  of  septicemia.  Death 
is  not  unusual  from  exhaustion,  from  septicemia,  from  dis- 
seminated tuberculosis,  from  tubercle  in  an  important  organ. 
or  from  amvloid  disease.  . 

r;r^/;«.v;A— Constitutionally,  the  treatment  is  directed 
acrainst  the  tubercular  diathesis.  Locally,  rest  is  of  the  first 
importance,  and  it  is  maintained  for  many  weeks,  it  being 


5l6   DISEASES  AND   INJURIES    OE  BONES  AND  JOINTS. 

obtained  by  splints,  by  a  plaster-of- Paris  bandage,  or  by  ex- 
tension appliances.  The  hot-air  apparatus  may  be  of  some 
benefit.  If  it  is  employed  it  should  be  used  daily,  the  limb  being 
immobilized  during  the  remainder  of  the  twenty-four  hours. 
Bier's  plan  of  inducing  congestive  hyperemia  may  do  good 
(p.  199).  Aspiration  can  be  used  for  fluid  accumulations. 
Caseous  masses  are  often  let  alone,  or  an  aspirator  is  used 
and  the  joint  drained,  washed  out  with  saline  solution,  and 
injected  with  an  emulsion  of  iodoform  and  glycerin  (10  per 
cent.).  Injections  of  balsam  of  Peru  or  of  iodoform  emul- 
sion about  the  joint  once  a  week  are  efficieht  in  some  cases. 
If  these  means  fail,  if  the  patient  gets  worse,  or  if  the  con- 
dition of  the  sufferer  renders  dangerous  the  prolonged 
conservative  course,  operate,  removing  the  entire  diseased 
area  by  erasion,  by  excision,  or  by  amputation.  Always 
remember  that  an  incomplete  operation  or  a  partial  removal, 
unless  it  consists  of  simple  drainage,  is  worse  than  no  opera- 
tion, as  it  opens  the  portals  to  systemic  infection,  and  may  be 
responsible  for  a  general  tuberculosis,  septicemia,  or  pyemia. 

Tuberculosis  of  Special  Joints. — Tuberculosis  of  the 
Sacro-iliac  Joint  (Sacro-iliac, Disease). — This  is  an  uncom- 
mon affection,  and  is  especially  rare  before  the  age  of  fifteen. 
The  disease  may  begin  in  the  joint,  may  arise  in  adjacent 
bones,  or  may  result  from  a  cold  abscess  burrowing  into  the 
joint.  In  some  cases  it  is  associated  with  extensive  disease 
of  the  pelvic  bones.  The  disease,  if  undetected,  may  lead 
to  dissemination  of  tubercle,  to  abscess,  or  even  to  death. 

Symptoms  are  often  obscure.  The  disease  is  often  con- 
founded with  vertebral  caries,  hip-joint  disease,  or  sciatica. 
The  patient  limps  on  walking,  but  can  stand  on  either  leg; 
there  is  pain  in  the  sacro-iliac  joint,  about  the  hip,  and  down 
the  thigh ;  tenderness  is  manifest  on  pressure  over  the  joint 
and  on  pushing  the  ilia  together ;  there  is  fulness  over  the 
sacro-iliac  joint;  but  the  hip  is  not  flexed  unless  iliac  abscess 
exists.^ 

Treatment. — Rest  in  bed  for  months,  using  also  a  felt  case 
for  the  pelvis.  Counter-irritation  by  blisters  and  the  actual 
cautery.  In  some  cases  injection  of  iodoform ;  in  others 
incision  and  curetting.  I  have  operated  on  four  cases,  with 
one  death.  In  one  case  in  the  Jefferson  Medical  College 
Hospital  the  abscess  was  pointing  in  both  the  back  and 
loin.  Both  areas  were  incised,  the  diseased  bone  was 
removed   and  the  boy  ultimately  recovered. 

Tuberculosis  of  the  Hip-joint  (Hip  Disease  ;  Morbus  Cox- 

1  See  A.  G.  Miller,  Edinburgh  Med.  Jour.,  May,  1895. 


TUBERCULOSIS    OF  SPECIAL  JOINTS.  517 

alius  ;  Morbus  Coxae  ;  Coxitis  ;  Hip-joint  Disease). — The 
primary  lesion  may  be  in  the  synovial  membrane,  but  it  is 
more  often  in  the  bone.  It  may  begin  in  the  acetabulum  ;  it 
may  begin  in  the  femur.  If  it  begins  in  the  femur,  it  usually 
arises  on  "  the  distal  side  of  the  epiphyseal  cartilage  "  (Senn). 
In  some  cases  primary  tuberculosis  arises  in  the  trochanter 
major,  and  may  never  involve  the  joint.  When  the  synovial 
membrane  becomes  involved  at  any  point,  spreading  through- 
out the  joint  is  rapid.  In  many  cases  the  articular  cartilages 
are  attacked,  and  in  some  cases  the  epiphyseal  cartilage  is 
destroyed.  It  is  commonest  in  children,  but  it  may  arise  in 
adults  and  even  occasionally  in  those  of  advanced  years  ;  62 
per  cent,  of  cases  arise  in  children  under  ten  years  of  age  and 
80  per  cent,  of  cases  occur  before  the  twentieth  year 
(Bryant).  Traumatism  and  cold  may  be  predisposing  causes. 
The  disease  strongly  tends  to  caseation  and  the  formation 
of  sequestra. 

Symptoms. — It  has  been  usual  to  divide  the  disease  into 
three  stages :  (i)  the  stage  of  microbic  deposition  and 
multiplication,  the  products  of  the  bacilh  causing  irritation 
and  new  growth;  (2)  the  stage  of  progression,  with  forma- 
tion of  masses  of  granulation-tissue  and  effusion  into  the 
joint ;  and  (3)  the  stage  of  caseation,  with  destruction  of  the 
joint  'and  often  of  the  structures  about  it.  Bradford  and 
Lovett^  protest  against  this.  They  say  :  "  It  has  been  cus- 
tomary to  divide  hip-disease  into  stages,  and  to  ascribe  to 
these  stages  certain  definite  symptoms.  Neither  from  a 
clinical  nor  a  pathological  point  of  view  is  it  desirable  to 
attempt  such  a  division."  As  H.  Augustus  Wilson  says  : 
"  Tubercular  bone  and  joint  disease  should  be  considered  as 
the  primary  invasion  or  incipiency,  and  all  other  symptoms 
should  be  regarded  as  results  and  not  as  an  integral  and 
necessary  part  of  the  trouble." 

The  symptoms  of  incipient  coxalgia  are  slight  and  may  be 
overlooked  entirely.  In  a  child  there  are  night-terrors; 
on  cretting  about  in  the  morning  the  child  shows  some 
lameness,  which  wears  off  during  the  day,  but  it  soon  grows 
tired  while  playing  and  lies  down  to  rest.  There  may  be 
a  slight  limp ;  a  slight  adductor  spasm  may  often  be  noted ; 
some  pain  may  occur  in  the  hip  on  tapping  the  sole  of  the 
foot  while  the  patient  is  recumbent  with  the  leg  extended  ; 
pain  may  be  complained  of  at  night  in  the  hip,  in  the  front 
of  the  thigh,  or  at  the  inside  of  the  knee.  The  diagnosis  in 
this  stage  is  more  or  less  problematical. 

1   Orthopedic  Su7-gery. 


5l8    DISEASES  AND   IjVJUKIES    OE  BOXES  AND  JO /NTS. 

As  the  disease  progresses  more  positive  symptoms 
are  observed.  The  child  hmps;  the  adductor  muscles  are 
rigid ;  the  hip  is  broadened  by  an  effusion  in  the  joint,  and 
fluctuation  may  possibly  be  detected ;  the  thigh-muscles  are 
atrophied;  the  extremity  is  pushed  forward,  abducted,  and 
everted  (the  patient  tilts  the  pelvis  so  as  to  rest  his  weight 
on  the  sound  limb).  In  some  few  cases  adduction  exists 
rather  than  abduction.  The  abduction,  which  is  usual, 
releases  tension  of  the  fascia  lata,  and  thus  abolishes  pressure 
upon  the  joint  through  lessening  of  pressure  upon  the  great 
trochanter  (AUis).  The  thigh  is  somewhat  flexed.  This 
flexion  relaxes  the  psoas  muscle  and  prevents  pressure  of 
its  tendon  upon  the  front  of  the  joint  (Allis).  Pain  exists, 
often  sudden  or  starting,  and  is  located  in  the  joint,  on 
the  front  of  the  thigh,  and  to  the  inner  side  of  the 
knee  in  the  course  of  the  obturator  nerve ;  the  pain 
is  aggravated  at  night ;  and  full  extension  and  complete 
abduction  are  not  possible.  The  gluteal  muscles  waste, 
and  the  gluteal  crease  is  on  a  lower  level  than  is  that 
of  the  sound  side.  The  gluteal  crease  may  be  nearly  or 
quite  effaced,  because  of  hypertrophy  of  the  subcu- 
taneous layer  (Alexandroff).  Jarring  of  the  heel  when 
the  extremity  is  in  extension  causes  pain  in  the  hip.  The 
above  symptoms  arise  chiefly  from  unconscious  efforts  to 
obtain  ease,  from  joint-effusion,  reflex  irritation,  and  invol- 
untary or  spasmodic  muscular  contractions.  There  is  an 
appearance  of  lengthening,  but  it  is  only  apparent,  not 
real.  The  position  is  shown  on  Plate  7,  Fig.  4.  The 
fluid  effusion  may  be  absorbed  or  may  find  its  way 
externally  by  means  of  sinuses.  The  latter  condition  is 
known  as  "  abscess  of  the  hip."  The  absorption  of  the 
exudate  or  the  rupture  of  the  capsule  permits  the  con- 
tracting muscles  to  bring  the  head  of  the  femur  into  firm 
contact  with  the  acetabulum  or  its  brim ;  the  bones  are 
worn  away  and  destroyed,  shortening  results,  abduction 
gives  way  to  adduction,  flexion  is  increased,  and  shortening 
occurs. 

In  advanced  cases  of  coxalgia  the  head  of  the  femur  goes 
upward  and  outward  upon  the  rim  of  the  acetabulum,  the 
thigh  is  flexed  and  fixed,  and  attempts  at  extension  when  the 
patient  is  recumbent  cause  the  pelvis  to  tilt  forward  and 
occasion  a  marked  lumbar  curve  (PI.  7,  P'ig.  2),  which  is  due 
to  the  pelvis  moving  with  the  femur  as  if  ankylosed,  and 
which  disappears  on  flexion.  In  this  condition  adduction 
occurs  because  of  the  ascent  and  movement  outward  of  the 


rrBEA'CULOS/S    OF  SPKCIAI.  JOIXTS. 


519 


head  of  the  bone.  Shortening  is  marked.  After  a  hip- 
abscess  finds  an  external  outlet  pyogenic  infection  is  very- 
apt  to  take  place  and  suppuration  arises,  which  is  followed 
by  that  state  which  is  designated  as  "  hectic."  If  a  cure 
follows  advanced  coxalgia,  partial  or  complete  ankylosis 
takes  place ;  if  death  ensues,  it  may  be  due  to  septicemia, 
tuberculosis  of  the  viscera,  exhaustion,  or  amyloid  degenera- 
tion. 

Diagnosis  is  very  easy  in  well-established  cases  of  hip  dis- 
ease, but  very  difficult  when  the  disease  is  incipient.  Always 
make  a  systematic  and  thorough  examination.  Undress  the 
patient  and  place  him  recumbent  upon  a  table  or  a  hard 
mattress,  with  the  legs  extended,  and  note  if  the  heels  are 
level  and  if  the  iliac  spines  are  on  the  same  level  (depressed 
spine  on  the  affected  side  means  abducted  extremity,  the 
degree  of  which  is  determined  by  carrying  the  limb  out  until 
the  spines  are  horizontal ;  elevation  of  the  iliac  spine  on  the 
affected  side  means  adduction,  the  amount  of  which  is  deter- 
mined by  adducting  the  limb  until  the  spines  are  horizontal 
(Fig.  166).    Try  all  the  movements  belonging  to  the  joint,  to 


Fig.  166. — Positions  in  hip-joint  disease  (alter  tlie  plan  of  Howard  Marsh  and  Treves). 
A. — ef,  lumbar  spine  ;  b  d,  limb  lixed  in  fle.vitm  and  abduction — useless  for  walking.  B. — e/, 
lumbar  spine.  Patient  corrects  the  condition  in  Figure  A  by  curving  the  lumbar  spine  for- 
ward and  rotating  the  pelvis  on  us  transverse  axis,  thus  making  the  femur  point  downward. 
The  lumbar  spine  is  curved  laterally,  the  pelvis  ascending  on  the  sound  side  and  descending 
on  the  affected  side  (apparent  lengthening),  c. — /' i^,  limb  fixed  in  flexion  and  adduction. 
u. — ej'.  curve  of  lumbar  spine  to  correct  condition  in  Figure  c  (apparent  shortening). 


detect  any  limitations  ;  try  if  bringing  down  the  knee  pro- 
duces lordosis  (PI.  7,  Figs,  i,  2);  look  for  swelling  and  for 
muscular  wasting;  feel  if  the  head  of  the  bone  is  enlarged; 
observe  if  motion  produces  pain  or  if  pressure  develops 
tenderness  ;  and  always  carefully  elicit  the  history  of  the 
attack,  of  the  person,  and  of  the  family. 

Hip  disease  may  be  confounded  with  spinal  caries  in  which 
a  psoas  or  a  lumbar  abscess  has  formed,  with  sacro-iliac  dis- 
ease, with  infantile  paralysis,  with  congenital  dislocation  of 
hip,  with  lordosis  from  rickets,  with  gluteal  abscess,  and  with 


520    DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS. 

bursitis  of  the  gluteal  bursae.  In  hip  disease  there  is  always 
some  lameness ;  pain  may  be  severe  or  may  be  absent 
entirely,  and  may  be  in  the  hip  or  be  referred  to  the  front 
of  the  thigh  or  the  inner  side  of  the  knee.  Always  remem- 
ber that  the  pain  is  not  characteristic,  and  that  pain  in  the 
same  localities  may  arise  from  aneurysm  of  the  femoral  or 
iliac  arteries,  from  abscess  in  Scarpa's  triangle,  from  caries  of 
the  lumbar  vertebrae,  from  sacro-iliac  disease,  and  from 
cancer  of  the  rectum.  Altered  position  of  the  limb,  limita- 
tion of  movement  in  the  hip-joint,  muscular  wasting,  and 
swelling  soon  arise  in  hip-joint  disease. 

In  disease  of  the  sacro-iliac  joint  examination  shows  that 
the  movements  of  the  hip-joint  are  unHmited  and  produce  no 
pain,  and  that  pain  is  developed  by  pressure  over  the  sacro- 
iliac articulation  and  by  pressing  the  ilia  together.  In  infan- 
tile paralysis  there  is  no  pain,  but  there  is  paralysis  with  great 
muscular  atrophy,  which  comes  on  with  considerable  rapid- 
ity. In  spinal  caries  with  psoas  abscess  the  evidences  of  dis- 
ease of  the  vertebrae  are  clear  and  the  tubercular  pus  is 
located  in  the  groin  external  to  the  femoral  vessels.  The 
tubercular  pus  of  hip-abscess  generally  gathers  under  the 
tensor  vaginae  femoris  muscle,  but  it  may  reach  Scarpa's 
triangle  by  passing  through  the  cotyloid  notch  or  through 
the  bursa  under  the  psoas  muscle;  it  may  even  appear 
under  the  glutei.  Matter  from  a  caseating  acetabulum  may 
reach  the  interior  of  the  pelvis  and  appear  above  Poupart's 
ligament. 

In  gluteal  bursitis  the  symptoms  last  for  many  months, 
and  do  not  remit  as  the  symptoms  of  early  hip  disease  are 
apt  to  do.  The  pain  is  but  moderate,  and  is  aggravated  by 
exercise,  but  passes  away  on  going  to  bed,  and  is  felt  back 
of  the  hip  and  back  of  the  knee.  There  are  a  certain 
amount  of  limitation  of  motion  and  a  positive  limp,  which 
arises  early.  In  marked  cases  fluctuation  can  be  detected 
in  the  upper  gluteal  region.^ 

Prognosis. — If  the  case  of  hip  disease  is  seen  early,  the 
chances  of  cure  are  excellent  in  children,  in  whom  the  dis- 
ease may  be  arrested  at  any  stage.  The  longer  the  duration 
of  the  disease  and  the  older  the  subject,  the  more  unfavor- 
able is  the  prognosis.  Many  months  will  be  required  to 
elapse  before  a  cure  can  be  effected,  and  advanced  cases 
only  get  well  by  means  of  ankylosis  with  shortening  and 
deformity.       Hip    disease    may   recur   years    after  apparent 

'  See  E.  G.  J3rackett's  important  paper  on  "Gluteal  Bursitis,"  in  The  Ttans- 
adions  of  the  American  Orthopedic  Associatio7t,  vol.  x. 


Ti-BERCi-LOS/S    OF  SPECIAL  JOEVTS.  521 

cure,  and  a  person  who  has  had  hip  disease  runs  a  strong- 
chance  of  developing  visceral  tuberculosis. 

Complications.— The    complications  that  may  accompan>- 
hip    disease    are    the    following:  Abscess,    as    above    noted. 
Tubercular   meningitis,  or   the   condition    known  as  ''acute 
hvdrocephalus"  or  "water  on  the  brain,"  may  arise  during 
the  progress  of  the  case  or  after  apparent  cure,  and  is  apt  to 
ensue  upon  incomplete  operations.     It  is  almost  inevitably 
fatal      Phthisis  piilmonalis  is  a  rare    complication,  but  is  a 
common  sequence,  being  apt  to  arise,  sooner  or  later,  after 
the    hip    disease    is    cured.     Amyloid,    lardaceous,  or   ivaxy 
deo-eneration  of  viscera  follows  upon  profuse  and  long-con- 
tinued suppurations,  and  is  apt  to  arise  in  the  liver,  spleen, 
kidnevs    or  intestinal  mucous   membrane.     Tuberculosis  is 
not  the'onlv  cause  of  amyloid  degeneration,  syphilis  being 
responsible  for  at  least  30  per  cent,  of  all  cases.     In  amyloid 
disease  of  the  liver  this  organ  is  much  enlarged,  smooth,  pain- 
less  and  of  increased  consistency,  there  is  no  jaundice,  the 
spleen  is  apt  to  be  enlarged,  and  albuminuria  is  the  rule.    In 
amvloid  kidney  large  amounts  of  pale  urine  of  low  specihc 
crravity    are   voided;  albumin    is    usually    present   in    large 
amount,  but  mav  be  absent;   globulin  may  often  be  found,  as 
mav   also  hyaline,  fatty,    or  granular  casts;  the  patient  is 
anemic,  and  dropsv  usually  exists.     Test  the   hyaline  casts 
with    iodin    for    amyloid    material.     Amyloid    changes    are 
usuallv    slow  in   onset,   but    they   may  be   rapid ,_  they  are 
commoner  in  men  than  in  women,  and  are  most  frequently 
encountered  in  individuals  between  the  ages  often  and  thirt\'. 
Slio-ht  amyloid  change  may  be  recovered  from,  but  an  exten- 
sivS  degeneration  brings  about  a  fatal  result.  J^ickinson  s 
theory  of  how  this  tissue-change  is  caused  is  that  the  How 
of  pus  drains  off  from  the  body  the  alkaline  salts,  especially 
the  salts   of  potassium,   which    drainage   results   m  visceral 
depositions  of  de-alkalinized  fibrin. 

Treatment.— \n  incipient  hip  disease  the  treatment  con- 
sists in  rest  Place  the  patient  upon  a  solid  mattress  and 
applv  extension.  In  children  under  ten  years  of  age,  use  a 
weio-'ht  of  from  three  to  five  pounds  ;  in  children  between  ten 
and^wenty,  use  a  weight  of  from  five  to  eight  pounds.  A 
long  splint  is  often  applied  to  the  sound  side  to  keep  the 
patfent  recumbent  and  horizontal.  Always  use  a  cradle  to 
hold  up  the  bed-clothing.  Apply  the  extension  in  the 
lono-  axis  of  the  limb,  the  extremity  being  placed  in  the 
hne  of  the  deformity  due  to  disease  and  being  supported  by 
piUows      In  lordosis  from  thigh-flexion,  raise  the  limb  until 


522    DISEASES  AND    INJURIES   OF  BONES  AND  JOINTS. 


the  iliac  spine  is  straight  (PI.  7,  Fig.  6).  If  the  spine  is  de- 
pressed on  the  affected  side,  abduct  the  Hmb  (PI.  7,  Fig.  8) ; 
if  the  spine  is  elevated,  abduct  the  hmb  until  the  spines  are 
horizontal  (PI.  7,  Fig.  7).  The  object  in  taking  these  precau- 
tions is  to  enable  the  extension  to  separate  the  femoral  head 
and  the  acetabulum.  Extension  will  remove  flexion  in  two 
weeks  in  a  recent  case  and  in  the  course  of  some  months  in 
an  older  case.  As  flexion  is  relieved  remove  the  pillows  and 
lower  the  leg  so  as  to  keep  up  extension  in  the  long  axis 
of  the  thigh.  Abduction  and  adduction  cannot  be  removed 
by  extension. 

Abduction  demands  no  special  treatment.  In  a  movable 
joint  it  will  disappear,  and  in  an  ankylosed  joint  it  is  an  ad- 
vantage, compensating  by  apparent  lengthening  for  the  short- 
ening due  to  bone-absorption  or  to  stunted  growth  of  the 
limb.  Adduction  requires  an  addition  of  several  pounds  to 
the  extension  weight,  the  use  of  a  long  splint  on  the  sound 
limb,  and  the  drawing  up  of  the  sound  limb  by  a  rope  and 
pulley  toward  the  head  of  the  bed.  The  weight  used  to  pull 
the  sound  side  toward  the  head  of  the  bed  is  equal  to  that 
used  to  pull  the  damaged  side  to  the  foot  of  the  bed.  This 
expedient  is  used  for  a  month  or  six  weeks.  In  old  cases 
where  the  weight  will  not  bring  about 
extension,  anesthetize  the  patient,  gen- 
tly straighten  the  limb  a  very  little,  and 
reapply  the  weight. 

Extension  in  a  mild  case  must  be 
continued  for  three  months  after  the 
symptoms  have  disappeared,  and  in  a 
severe  case  the  period  must  be  six 
months.  The  weight  is  gradually 
taken  off;  if  symptoms  recur,  tlie 
weight  is  reapplied ;  if  they  do  not 
recur,  apply  a  traction  splint  or  a 
plaster  dressing,  put  a  high-heeled 
boot  on  the  sound  limb,  and  send  the 
patient  out  on  crutches.  In  young 
children  extension  can  be  made  while 
the  child  is  in  a  wheeled  carriage,  thus 
enabling  the  patient  to  go  out  in  the 
fresh  air  and  sunlight.  The  general 
treatment  is  tonic  and  restorative. 
The  joint  is  so  deeply  placed  that 
external  applications  are  useless.  In  the  treatment  of  hip 
disease  Thomas's  splint  (Fig.    167)  is  used  by  many,  and  it 


Fig.  167,— Thomas's  posierior 
splint. 


HIP-JOINT    DISEASE. 


Plate  7. 


I,  2.  Effects  on  the  Lumbar  Spine  of  Flexing  and  Extending  the  Diseased  Leg  in  Hip  Disease 
(Albert).  3,  4.  Positions  in  Coxalgia  (Albert).  5.  Strap-and-slipper  Apparatns  for  Fracture  of  Pos- 
terior Portion  of  the  Calcaneum  (after  Hamilton).  6.  Extension  in  Hip  Disease  (Treves).  7.  Exten- 
sion of  the  Limb  in  a  Flexed  and  Adducted  Position  (Treves).  8.  Extension  of  the  Limb  in  a  Flexed 
and  Abducted  Joint  (Treves). 


TUBERCULOSIS    Ol<   SPECIAL  JOINTS. 


523 


may  be  combined  with  weight  extension  ;  or  Sayre's  spUnt 
(Fig.  168)  maybe  employed.  Wyeth's  apparatus  (Fig.  169) 
is  a  favorite  with  many  American  surgeons. 

If  the  limb  is  in  good  position,  or  has  been  brought  into 
good  position,  either  by  weight  extension  or  straightening 
under  ether,  plaster  of  Paris  is  a  useful  dressing.  It  is  put 
on  from  the  toes  up,  and  includes  the  entire  extremity  and 
also  the  pelvis.  A  patient  dressed  by  plaster  may  get  about 
on  crutches  when  the  sole  of  the  other  foot  is  raised.     If 


Fig, 


-Sayre's  long  splint. 


Fig.  169. — Wyeth's  combination  method. 


a  case,  in  spite  of  treatment,  does  not  improve  or  becomes 
worse,  use  intra-articular  injections  of  iodoform.  Always 
try  these  injections  before  doing  a  resection.  Sometimes 
they  succeed  and  render  resection  unnecessary.  Asepti- 
cize the  surface,  carry  a  small  aspiratmg-needle  into  the 
joint,  irrigate  the  joint  with  salt  solution,  and  inject  a  sterile 
emulsion  of  iodoform  and  glycerin  (10  per  cent.).  In 
one  week,  if  reaction  has  ceased,  repeat  the  injection.  In 
another  week  repeat  it  again.     It  may  be  necessary  to  give 


524   DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS. 

from  ten  to  twenty  injections.  The  proper  spot  for  puncture 
is  thus  determined :  Draw  a  Hne  from  a  point  half  an  inch 
outside  of  the  middle  of  Poupart's  ligament  to  the  outer  edge 
of  the  great  trochanter.  Puncture  at  the  middle  of  the 
outer  half  of  this  line  (DeVos). 

If  an  abscess  forms,  incise  it  with  the  most  thorough  anti- 
septiccare,  let  the  fluid  drain  away,  wash  out  with  salt  solu- 
tion, remove  any  sequestra,  inject  with  iodoform  emulsion, 
insert  a  tube,  and  dress  antiseptically.  In  some  cases  the 
sequestrum  is  extra-articular.  In  some  cases  no  sequestrum 
is  found.  The  old  plan  of  not  operating  until  rupture  was 
seen  to  be  inevitable  was  bad.  To  open  early  and  antiseptic- 
ally  often  means  rapid  healing,  the  prevention  of  burrowing, 
a  lessened  danger  of  visceral  infection,  and  an  earlier  cure. 
Hectic  will  rarely  arise  if  the  abscess  is  opened  with  antisep- 
tic care. 

Excision  of  the  hip  is  to  be  performed  when  the  head  of 
the  femur  is  detached  and  lies  loose  in  the  joint ;  when  pro- 
fuse suppuration  continues  for  a  long  time,  and  other  methods 
fail  to  arrest  it ;  when  amyloid  disease  is  beginning ;  or  when 
very  faulty  position  is  inevitable  without  operation.  Excision 
is  an  operation  of  considerable  danger,  and  the  older  the 
person  the  greater  the  danger.  Schede  advocates  arthrec- 
tomy  in  some  case  as  a  substitute  for  resection.  Senn  tells 
us  that  opinion  as  to  resection  has  greatly  changed  of  late, 
and  the  operation  is  advisable  in  all  cases  where  fixation,  ex- 
tension, intra-articular  and  parenchymatous  injections  have 
failed  to  arrest  the  disease  (Senn  on  Tuberculosis  of  Bones 
and  Joints^.  When  there  is  extensive  disease  of  the  femur, 
when  excision  has  been  tried  and  has  failed,  or  when  the 
patient  has  not  the  recuperative  power  to  stand  the  long 
siege  following  excision,  amputate.^  Amputation  of  the  hip- 
joint  for  tubercular  disease  is  a  very  successful  procedure. 

Knee-joint  Disease  (White  Swelling). — After  the  hip,  the 
knee  is,  of  all  joints,  the  commonest  .site  for  tubercular  dis- 
ease. Knee-joint  disease  can  begin  as  a  synovitis,  but  oftener 
begins  as  tubercular  inflammation  of  the  femoral  or  the 
tibial  epiphysis.  The  disease  rarely  attacks  the  bone  above 
the  epiphyseal  line  ;  a  single  focus  only  exists  as  a  rule,  and  a 
sequestrum  is  rarely  formed.  In  very  rare  instances  the  pa- 
tella or  the  semilunar  cartilage  is  primarily  attacked.  It  may 
begin  at  any  age,  but  is  most  common  in  children  and  young 
adults.  If  an  acute  synovitis  ushers  in  the  case,  there  may 
be  a  large  effusion  into  the  knee-joint  and  partial  flexion,  but 

^  See  the  admirable  article  of  Howard  Marsh   in  Treves's  Manual  oj  Surgery. 


TUBERCULOSIS   OF  SPECIAL  JOL\'TS. 


525 


swelling  is  usually  slight  in  knee-joint  disease.  Pulpy  de- 
generation of  the  synovial  membrane  occurs ;  the  joint 
enlarges ;  the  ligaments  soften ;  the  skin  becomes  edem- 
atous, and  muscular  spasm  arises.  The  leg  is  flexed ;  the 
bones  are  displaced  backward  and  outward,  the  foot  being 
everted;  lameness  exists,  due  chiefly  to  deformity.  Pain  may 
be  absent,  is  often  slight,  and  is  rarely  severe.  When  the 
disease  begins  in  the  bone  or  an  epiphysis  there  are  pain,  ten- 
derness, lameness,  swelling,  inability  to  extend  the  limb  com- 
pletely, sudden  spasmodic  muscular  contractions,  and  final 
involvement  of  the  joint.  When  an  abscess  forms,  it  may 
destroy  the  joint  very  rapidly  or  it  may  break  externally. 

Treatment. — In  treating  knee-joint  disease  employ  general 
antitubercular  treatment  and  locally  apply  iodoform  oint- 
ment or  guaiacol.  A  useful  plan  is  to  make  a  mixture  of 
guaiacol  and  tincture  of  iodin  or  guaiacol  and  olive  oil  (i  : 
4).  Once  a  day  the  joint  is  exposed  by  removing  dressings, 
is  painted  with  this  mixture,  and  the  painted  surface  is  cov- 
ered with  cotton-wool.  Rest  is  of  the  first  importance,  and 
may  be  secured  by  the  application  of  splints  (Figs.  170,  171), 
the  use  of  extension  (Fig.  172),  or  the  employment  of  a 
plaster-of-Paris  bandage.  In  any  case  the  patient  must  be 
kept  in  bed  for  a  few  weeks  ;  he  may  then  be  permitted  to 
go  out  upon  crutches,  wearing  a  high-heeled  shoe  upon 
the  sound  foot.  In  cases 
in  which  treatment  is  begun 
early  the  disease  may  often 
be  arrested  in  from  eight 
to  twelve  months.  If  the 
symptoms  do  not  abate 
after  a  number  of  weeks,  or 
if  the  condition  grows  worse 
and  caseation  occurs,  aspir- 
ate, irrigate,  and  inject  iodo- 
form emulsion.  Intra-articu- 
lar  injections  are  not  unusu- 
ally curative.  Insert  the 
needle  in  the  angle  between 
the  outer  edge  of  the  patella 
and  the  ligament  of  the 
patella  (DeVos).  Repeat 
the  injection  in  one  week  if 
reaction  has  abated,  and 
continue  as  directed  for  the 
injection  of  the  hip-joint.     If  this  plan  fails,  incise  the  cap 


Fig.   170.  — Sayre's     Fig.  171. — Hutchinson's 
knee  splint  applied.  knee-joint  splint. 


526   DISEASES  AND   INJURIES    OE  BONES  AND  JOINTS. 

sule,  remove  all  fragments  and  tubercular  foci,  irrigate  with 
normal  salt  solution,  inject  iodoform  emulsion,  and  sew  up 
without  drainage  (Neuber's  plan).  A  more  severe  case 
requires  drainage.  If  these  means  fail,  or  if  the  case  is  too 
far  advanced  to  permit  of  their  use,  open  the  joint  and  per- 
form an  excision  or  an  erasion  (page  605).  Some  cases 
demand  amputation,  which,  if  the  patient's  health  is  much 
impaired,  is  to  be  preferred  to  excision.  Amputation  is  pre- 
ferred to  excision  in  very  young  children  and  aged  people. 


Fig.  172. — Sayre's  double  extension  of  the  knee-joint. 

Ankle-joint  disease  may  begin  in  the  synovial  membrane, 
in  the  tibial  epiphysis,  or  in  the  tarsus,  but  the  origin  is 
usually  synovial.  The  syniiptovis  are  pain,  swelling,  lame- 
ness, limitation  of  joint-movements,  and  atrophy  of  the  calf- 
muscles.     Caseation  often  occurs,  and  sinuses  form. 

Treatment. — The  treatment  consists  in  the  employment 
of  antitubercular  remedies,  applications  of  guaiacol  or  iodo- 
form ointment  over  the  joint,  and  rest  obtained  by  means 
of  splints  or  plaster-of-Paris  bandages.  Caution  the  patient 
to  avoid  standing  upon  the  diseased  extremity.  Injections 
of  iodoform  emulsion  may  do  good.  Insert  the  needle 
below  the  outer  malleolus.  When  caseation  occurs,  it  is 
often  advisable  to  open,  wash  out  with  normal  salt  solu- 
tion, inject  iodoform  emulsion,  sew  up  the  incision,  and  put 
up  the  ankle-joint  in  plaster.  When  joint-disorganization 
occurs,  perform  an  excision  or  an  erasion.  Some  cases 
demand  amputation  (Syme's  amputation  being  preferred 
by  some,  amputation  above  the  ankle  being  approved  by 
many).  Osteoplastic  resection  is  sometimes  advised  (Wlad- 
imiroff-Mikulicz  operation). 

Shoulder-joint  disease  is  not  common  ;  it  is  rare  in  chil- 
dren and  is  commonest  in  adults  ;  it  begins  either  in  the 
synovial  membrane  or  in  the  head  of  the  humerus.    The  gle- 


TUBERCULOSIS    OF  SPECIAL  JOINTS.  SV 

noid  cavity  is  rarely  attacked.  Pain  is  slight,  atrophy  of  the 
deltoid  and  other  muscles  is  noted,  the  joint  is  stiff,  and  the 
scapula  follows  the  motions  of  the  humerus.  Caries  sicca  is 
the  usual  cause  of  destruction.  In  many  cases  swelling  is 
not  obvious,  the  joint  shrinking  because  of  destruction  of  the 
head  of  the  bone  and  contraction  of  the  capsule  (Senn). 
Abscess-formation  is  unusual.  If  an  abscess  forms,  it  may 
open  in  the  axilla,  the  deltoid  muscle,  or  at  some  far  distant 
point. 

Treatment.— \\\  treating  shoulder-joint  disease  employ  anti- 
tubercular  remedies  and  hygienic  measures,  and  apply  to  the 
skin  over  the  joint  guaiacol  or  iodoform  ointment.  Put  on  a 
shoulder-cap,  apply  the  second  roller  of  Desault,  and  hang 
the  hand  in  a  sling.  Maintain  rest  for  at  least  four  months. 
Aspiration  and  injection  ^f  iodoform  emulsion  are  of  great 
service  in  synovial  tuberculosis.  The  needle  is  entered  below 
the  acromion,  while  the  arm  is  held  against  the  side  and  the 
forearm  is  at  right  angles  to  the  arm  and  across  the  front 
of  the  chest  (DeVos).  If  caseation  occurs,  open  the  joint, 
remove  tubercular  foci,  wash  with  hot  saline  fluid,  inject  iodo- 
form emulsion,  and  close  without  drainage,  or,  in  a  rather 
severe  case,  drain.  In  rare  instances  dead  bone  will  have 
to  be  gouged  away.  Caries  sicca  may  occur.  Excision  is 
sometimes  required. 

Elbow-joint  disease  may  begin  in  the  humerus  or  the 
ulna.  The  head  of  the  radius  is  rarely  the  primary  focus. 
In  some  cases  the  synovial  membrane  is  first  attacked.  The 
disease  is  most  frequent  in  young  adults.  The  joint  is 
swollen,  its  movements  are  somewhat  limited,  muscular 
wasting  is  pronounced,  and  pain  is  generally  slight.  Tuber- 
cular pus  may  form. 

Treatment. — In  treating  elbow-joint  disease,  employ  anti- 
tubercular  foods,  drugs,  and  hygienic  measures;  iodoform 
ointment  or  guaiacol  locally ;  rest  by  means  of  an  anterior 
angular  splint  (Fig.  173)  and  a  triangular  sling.  Splints  are 
to  be  worn  for  from  four  months  to  a  year.  Injection  of 
iodoform  emulsion  may  be  u.seful.  Insert  the  needle  for 
injection  by  the  side  of  the  olecranon.  It  may  become 
necessary  to  open  the  joint.  If  the  condition  is  found  to 
admit  of  it,  Neuber's  plan  should  be  followed ;  but  if  there 
is  advanced  disease  of  the  joint,  drain  with  a  tube  or  perform 
an  erasion  or  an  excision. 

"Wrist-joint  disease  may  arise  at  any  age,  and  is  some- 
times met  with  in  late  middle  life,  or  even  in  old  age.  The 
joint  presents  a  puffy  swelling,  loses  its  normal  contour,  and 


528    1)/SEASES  AND    INJURIES    OE  BONES  AND  JOINTS. 

becomes  spindle-shaped.  Hand-movements  are  impaired, 
pronation  and  supination  cannot  completely  or  satisfactorily 
be  performed,  the  joint  is  stiff  and  partly  flexed,  the  grasp  is 
enfeebled,  pain  may  be  severe  or  slight,  the  skin  is  usually 
hot,  and  muscular  atrophy  is  marked.  This  form  of  tuber- 
culosis may  begin  in  the  synovial  membrane,  in  the  bones, 
or  in  the  tendon-sheaths. 

Treatment  comprises  the  usual  antitubercular  measures 
and  drugs,  and  the  local  application  of  guaiacol  or  iodoform 
ointment.  Apply  a  Bond  splint  and  sling  or  put  on  a  plaster 
bandage,  and  maintain  rigid  rest  for  from  four  to  six  months. 
Aspiration  and  injection  of  iodoform  emulsion  are  often  useful. 
Enter  the  needle  at  the  dorsal  edge  of  the  radial,  styloid  proc- 
ess, and  again  at  the  upper  edge  of  the  pisiform  bone  (DeVos). 
In  some  cases  it  is  well  to  incise,  wash  with  salt  solution,  in- 


FiG.   173- — Stromeyer's  anterior  angular  splint. 

ject  iodoform  emulsion,  and  close  without  drainage.  Severe 
cases  demand  incision  and  drainage  with  the  maintenance  of 
rest.  A  moderate  amount  of  caries  is  treated  by  drainage 
and  rest.  Necrosis  demands  removal  of  the  sequestra.  Ex- 
ten.sive  caries  requires  excision. 

Acute  Suppurative  Arthritis. — This  infection  is  usually 
due  to  the  staphylococcus  pyogenes  aureus  or  to  the  strepto- 
coccus pyogenes,  which  find  entrance  by  means  of  a  wound,. 
by  the  spontaneous  evacuation  into  a  joint  of  the  products 
of  an  osteomyelitis,  by  extension  of  suppurative  inflammation 
through  contiguous  structures  or  by  the  blood-stream.  In 
this  disease  all  the  joint-structures  are  involved  and  suppura- 
tion rapidly  appears.  It  is  very  rarely  due  to  gonorrhea,  and 
sometimes  to  septicemia. 

Symptoms. — The  symptoms  of  acute  suppurative  arthritis 
are  usually  a  chill  followed  by  fever  and  a  rapid  pulse. 
There  is  severe  pain,  which  is  aggravated  by  motion  and  is 
worse  at  night ;  discoloration,  heat,  and  edema  of  the  skin ; 


TUBERCULOSIS   OF  SPECIAL  JOIXTS.  529 

partial  flexion  of  the  joint ;  fluctuation  ;  and  marked  consti- 
tutional symptoms  of  sepsis.  The  joint  tends  to  rapid  dis- 
organization, and  fatal  septicemia  is  very  apt  to  occur.  In 
pyemic  arthritis  several  joints  become  infected. 

Trcatiiicnt. — The  treatment  in  septic  arthritis  consists  in 
prompt  incision,  evacuation,  antiseptic  irrigation,  drainage, 
antiseptic  dressing,  and  immobilization.  Cure  is  followed, 
as  a  rule,  by  ankylosis,  but  in  cases  treated  early  the  joint 
ma}'  be  preser\-ed. 

Infective  arthritis  arises  in  the  course  of  an  acute  infec- 
tious disease  (such  as  er}"sipelas,  typhoid  fever,  influenza, 
mumps,  dysenter}',  diphtheria,  measles,  scarlatina,  variola), 
and  may  be  due  to  p\'ogenic  cocci,  to  the  specific  micro- 
organism of  the  acute  infectious  disease,  or  purely  to  micro- 
bic  pj-oducts.  Joint-inflammation  arising  in  the  course,  or  as 
a  sequel,  of  an  acute  infectious  disease  may  or  may  not 
suppurate. 

Symptoms  and  Treatment. — If  no  suppuration  takes  place, 
the  symptoms  of  the  attack  resemble  those  of  rheumatism ; 
if  suppuration  occurs,  the  symptoms  are  the  same  as  those 
of  acute  suppurative  arthritis,  with  which  disease  this  form  of 
infective  arthritis  is  identical.  Suppuration  rarely  occurs. 
Ashby  has  well  described  the  arthritis  which  sometimes 
follows  scarlatina.  It  involves  the  wrists,  finger-joints,  ten- 
dons of  the  forearms,  the  knees,  ankles,  or  spine.  The 
joints  are  painful,  but  are  rarely  much  swollen  or  discolored 
(Howard  ]\Iarsh). 

That  the  organism  of  t}-phoid  may  inflame  the  joints  is 
proved  (Klemm,  Quincke,  and  others),  but  whether  it  does 
cause  suppuration  has  been  disputed.  Some  claim  that  mixed 
infection  induces  suppuration.  The  typhoid  bacilli  enter  the 
bones  in  many  typhoid  cases  and  sometimes  cause  bone-dis- 
ease. Joint-disease  is  more  common  than  bone-disease.  Ty- 
phoid disease  of  a  joint  begins  when  the  fever  is  abating,  and 
more  than  one  joint  may  be  involved.  T}'phoid  joints  may 
recover  permanently,  may  become  ankylosed,  may  dislocate, 
or  the  joint-disease  may  lead  to  a  fatal  sepsis.  \Ve  can  dis- 
tinguish infective  arthritis  from  rheumatism  by  the  fact  that 
it  does  not  migrate,  and  is  uninfluenced  b\'  antirheumatic 
remedies.  In  slight  cases  the  synovial  membrane  only  is 
involved;  in  more  severe  cases  capsule,  cartilages,  liga- 
ments, and  even  bones  are  involved.  Some  cases  suppu- 
rate. Keen  tells  us  that  septic  t}-phoid  arthritis  results 
from  a  mixed  infecton  with  typhoid  bacilli  and  pyogenic 
bacteria,  and  is  identical  in  s}-mptoms  and  progress  with  an 
34 


530  DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS 

ordinary  septic  arthritis.  The  same  author  points  'out  that 
typhoid  arthritis  proper  may  be  monarticular  or  polyarticular, 
the  monarticular  form  being  the  most  common,  and  the  hip- 
joint  being  the  articulation  most  liable  to  attack.  In  most 
cases  typhoid  arthritis  causes  but  little  pain.  The  swellmg 
is  marked,  although  in  the  hip  it  is  concealed.  Pus  rarely 
forms.  Keen  calls  attention  to  the  fact  that  in  the  eighty- 
four  cases  he  collected,  spontaneous  dislocation  occurred  in 
forty-three,  nearly  all  in  the  hip.^ 

Treatment  of  a  mild  case,  as  for  simple  synovitis :  if  there 
is  much  fluid  in  the  joint,  aspirate  and  wash  out  with  normal 
salt  solution.     If  pus  forms,  open,  irrigate,  and  drain. 

Gonorrheal  Arthritis  or  Gonorrheal  Rheumatism. — 
During  the  progress  of  gonorrhea  every  rheumatic  attack  is 
not  gonorrheal  rheumatism,  for  ordinary  rheumatism  is 
just  as  likely  to  arise  when  a  man  has  clap  as  when  he  has 
not  this  malady.  Furthermore,  the  term  is  inaccurate,  as 
gonorrheal  rheumatism  is  not  rheumatism  at  all,  but  is  an 
infective  disorder  of  the  joints  or  of  the  synovial  membranes, 
the  infective  material  being  contained  primarily  in  the  urethral 
discharge.  Occasionally  this  form  of  arthritis  arises  from 
gonorrheal  ophthalmia  (Heiman's  case) ;  it  sometimes, 
though  rarely,  arises  during  the  height  of  a  gonorrhea, 
but  it  is  more  frequently  met  with  in  chronic  cases  or  when 
the  intensity  of  the  inflammation  is  abating  in  acute  cases. 
Men  suffer  from  gonorrheal  arthritis  far  more  frequently 
than  do  women,  and  the  seizure  is  very  apt  to  recur  again 
and  again.  In  some  cases  many  joints  are  involved,  but 
in  most  cases  only  a  few  joints  suffer.  Osier  states  that 
the  knees  and  ankles  are  most  apt  to  be  involved  in  gonor- 
rheal rheumatism,  and  that  this  form  of  arthritis  is  peculiar 
in  often  attacking  joints  that  are  apt  to  be  exempt  in  acute 
rheumatism  ("the  sternoclavicular,  the  intervertebral,  the 
temporomaxillary,  and  the  sacro-iliac ").  There  are  two 
forms  of  gonorrheal  rheumatism,  an  acute  and  a  chronic 
form. 

Changes  In  and  About  the  Joint. — The  inflammation  of 
gonorrheal  arthritis  may  be  located  around  rather  than  m 
the  joint,  and  especially  in  the  tendon-sheaths.  Suppuration 
is  unusual,  but  it  may  occur  in  joints  and  in  tendon-sheaths 
Cultivation  of  the  exudate  may  or  may  not  show  the  gono- 
cocci.  Cover-glass  preparations  stained  by  Gram's  method 
may  show  gonococci.  Osier  suggests  that  the  non-suppura- 
tive  cases  are  due  to  the  action  of  toxins  taken  up  from  the 

'  Keen  on  J7ie  Sufgical  Co^nplicalions  and  Sequels  of  Typhoid  F(ver. 


TUBERCULOSIS    OF  SPECIAL  JOINTS.  53  I 

area  of  primary  infection,  and  that  the  suppurative  cases  are 
due  to  infection  with  pyogenic  bacteria. 

Sviuptoins. — The  acute  form  attacks  as  a  rule  but  a  single 
joint,  but  may  attack  several  joints.  The  joint  trouble  begins 
with  great  suddenness,  and  is  often  ushered  in  by  chilly 
sensations  or  by  a  distinct  chill.  Moderate  fever  arises. 
The  pain  in  the  joint,  severe  from  the  first,  becomes  atrocious. 
In  superficial  joints  the  skin  is  red  and  hot,  and  peri-articular 
edema  is  very  evident.  The  fluid  in  the  joint  is  in  most 
cases  serous,  but  may  become  purulent.  If  it  becomes  puru- 
lent, the  fever  becomes  very  high  and  chills  may  occur. 

A  chronic  condition  may  follow  the  acute,  but  the  condi- 
tion may  be  chronic  from  the  start.  The  symptoms  resemble 
those  of  the  acute  form,  but  are  far  milder,  although  acute 
exacerbations  may  occur.  The  joint-fluid  is  usually  serous.^ 
In  gonorrheal  arthritis  there  may  be  transitory,  intermittent, 
and  wandering  pain  in  and  about  the  joint,  without  any 
other  symptom  ;  one  or  more  joints  may  become  swollen  and 
painful,  and  moderate  fever  may  develop.  One  joint,  espe- 
cially the  knee,  may  swell  to  an  enormous  extent,  pain,  peri- 
articular edema,  redness,  and  fever  being  absent  (hydrar- 
throsis, or  dropsy  of  a  joint).  Suppuration  in  this  form  is 
rare.  The  tendons,  the  tendon-sheaths,  the  bursas,  and  the 
periosteum  may  inflame.  Whether  the  joints  are  inflamed 
or  not  inflamed,  the  tendon-sheaths  about  the  wrist  and 
ankle  and  the  retrocalcaneal  bursae  are  apt  to  suffer.  In 
some  cases  numerous  bursse  are  involved.  A  case  of  gon- 
orrheal arthritis  is  often  very  hard  to  check.  It  may  last 
for  a  long  period,  and  tends  to  recur  again  and  again.  Iritis, 
pleuritis,  endocarditis,  and  pericarditis  have  been  observed 
as  complications.  In  some  cases  gonococci  have  been  found 
in  the  joint-fluid;  in  other  cases  they  have  not  been  found. 
It  seems  probable  that  in  mild  cases  only  toxins  reach  the 
joints. 

The  diagnosis  between  gonorrheal  arthritis  and  acute 
rheumatism  rests  chiefly  on  the  great  chronicity,  the  slight 
degree  of  fever,  the  excessive  tendency  to  recurrence,  and 
the  absence  of  profuse  acid  sweats  in  gonorrheal  rheuma- 
tism ;  and  on  the  shorter  course,  the  higher  fever,  the  pro- 
fuse acid  sweats,  the  lesser  tendency  to  rapid  recurrence, 
the  greater  proneness  to  symmetrical  involvement,  and  the 
great  liability  to  cardiac  and  visceral  complications  in  rheu- 
matic fever.  Furthermore,  in  gonorrheal  arthritis  a  gonor- 
rheal infection  (urethral  or  ocular)  certainly  exists  or  recently 

1  See  SchuUer  in  Aerztl.  Tract.,  No.  17,  1896. 


532    DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

existed;  in  ordinary  rheumatism  a  urethral  discharge  may, 
of  course,  happen  to  be  present.  Gonorrheal  arthritis  is 
apt  to  affect  certain  joints  which  acute  rheumatism  rarely 
attacks. 

Treatment. — The  salicylates,  the  alkalies,  and  salol  are  use- 
less ;  iron,  arsenic,  and  strychnin  are  of  some  benefit.  Quinin 
is  distinctly  helpful  in  some  cases.  lodid  of  potassium 
seems  to  be  of  some  value.  The  inflamed  joints  should  be 
wrapped  in  cotton  and  bandaged,  and  every  day  a  little  blue 
ointment  should  be  rubbed  into  the  skin  about  them.  If  the 
inflammation  lingers,  use  the  hot-air  oven,  massage,  and 
gentle  passive  motion,  apply  blisters,  or  counterirritate  with 
the  hot  iron.  If  the  inflammation  still  lingers,  or  if  it  becomes 
worse,  aspirate,  wash  out  the  joint  with  hot  normal  salt 
solution,  and  inject  iodoform  emulsion.  If  pus  forms,  incise, 
irrigate,  drain,  and  immobilize.' 

Rheumatic  Arthritis. — Acute  rheumatism  is  a  self-limited 
febrile  malady  whose  characteristic  features  are  polyarthritis, 
profuse  acid  sweats,  and  a  tendency  to  heart-involvement. 

Symptoms  of  Acitte  RJicuinatisni. — In  acute  rheumatism  the 
case  begins  with  malaise  and  fever,  and  one  or  more  joints 
become  affected.  The  inflammation  spreads  from  joint  to 
joint,  is  apt  to  be  symmetrical,  and  when  it  arises  in  fresh 
joints  usually  disappears  quickly  in  those  previously  af- 
fected. The  temperature  is  high,  the  skin  sweats  profusely, 
the  joints  are  red,  swollen,  hot,  and  excruciatingly  painful, 
and  the  structures  about  the  joints  are  edematous.  After  a 
short  time  the  inflammation  subsides  in  one  joint  and  passes 
into  another,  the  joint  first  attacked  regaining  its  functions. 
Suppuration  does  not  take  place.  Anemia  is  pronounced, 
exhaustion  is  profound,  the  sweat  is  sour,  the  saliva  is  acid ; 
the  urine  is  acid,  scanty,  high-colored,  often  contains  albu- 
min, and  is  deficient  in  chlorids.  Cardiac  disease  is  apt  to 
be  produced  (endocarditis,  pericarditis,  or  myocarditis).  Nod- 
ules may  form  upon  fibrous  structures,  hyperpyrexia  is  not 
unusual,  and  cerebral  or  pulmonary  complications  may 
occur. 

Chronic  rheinnatisni  rarely  follows  repeated  attacks  of  acute 
rheumatism,  but  rather  arises  insidiously  in  people  who  have 
been  exposed  to  cold  and  damp,  who  have  suffered  from 
poverty,  hardship,  and  privation,  or  who  have  had  much 
worry.  The  capsule  and  the  tendon-sheaths  thicken,  and 
there  is  usually  but  little  effusion  in  the  joint,  but  the  ar- 

^  See  SchuUer,  y^^rs//.  Pract.,  No.  17,  1896,  and  Monats.  iiber  d.  Krank- 
heiten  d.  Ham.  und  Sexual  Apparatus,  1897,  p.  30. 


TUBERCULOSIS   OF  SPECIAL  JOIXTS.  533 

ticLilation  becomes  stiff  and  painful.     The  joint-cartilages  are 
occasionally  eroded.     Muscular  atrophy  occurs. 

Symptoms  of  Chronic  RhcuDiatism. — In  chronic  rheuma- 
tism the  affected  joints  are  stiff  and  painful  and  are  a 
little  swollen,  but  not  red.  Dampness  and  cold  aggravate 
the  symptoms.  One  joint  or  many  may  be  affected,  but 
usually  several  are  invoh'ed.  Passive  movements  cause  the 
joint  to  creak  and  develop  crepitus  in  the  tendon-sheaths. 
The  muscles  are  wasted.  The  joints  may  ankylose.  Anemia 
is  usualh-  pronounced.  There  is  no  fever  and  no  tendency 
to  suppuration,  and  the  disease  is  incurable. 

The  treatment  of  acute  rheumatism  comprises  the  use  of 
alkalies,  saHcylates,  etc.  (See  a  book  upon  practice  of  medi- 
cine, as  acute  rheumatism  is  in  the  physician's  province.)  In 
chronic  rheumatism  maintain  the  general  health  of  the  pa- 
tient, give  courses  of  iron,  arsenic,  and  strychnin,  and  an  occa- 
sional course  of  iodid  of  potassium  or  a  salt  of  lithium,  and, 
if  possible,  send  him  every  winter  to  a  warm  climate.  Turk- 
ish baths  give  considerable  temporary  relief.  The  waters 
and  regimen  of  Carlsbad  and  Vichy  are  of  positive  though 
temporary  benefit,  and  the  sufferer  may  obtain  relief  at  the 
hot  springs  of  Virginia.  The  patient  must  avoid  damp  and 
must  wear  woollens.  Frictions,  the  douche,  massage,  fl}'ing 
blisters,  counterirritation  with  the  hot  iron,  ichthyol  ointment, 
and  mercurial  ointment  are  of  benefit.  Subjecting  the  dis- 
eased joint  to  a  very  high  temperature  by  placing  it  daily  in 
a  hot-air  apparatus  often  does  great  good.  In  partial  anky- 
losis it  is  proper  in  some  cases  to  give  ether  and  break  up 
the  adhesions. 

Gouty  arthritis,  which  appears  especially  in  the  smaller 
joints  (as  the  fingers  and  the  metatarsophalangeal  joints  of 
the  great  toes),  is  due  to  a  deposition  of  urate  of  sodium  in  the 
joint  and  in  the  periarticular  structures.  The  irritant  urate 
of  sodium  causes  inflammation,  inflammation  leads  to  the 
formation  of  granulation-tissue,  granulation-tissue  is  con- 
verted into  fibrous  tissue,  and, the  fibrous  tissue  contracts 
and  thus  deforms  the  joint  and  Hmits  its  mobility.'.  A  great 
mass  of  urates  in  a  joint  constitutes  a  "  chalk-stone." 

Symptoms. — The  premonitoiy  symptoms  may  be  observed 
for  a  day  or  so,  but  the  acute  seizure  usually  occurs  early  in 
the  morning,  the  patient, as  a  rule,  being  aroused  by  excruciat- 
ing pain  in  the  metatarsophalangeal  articulation  of  one  of  the 
great  toes.  The  joint  swells,  and  the  skin  over  it  feels  hot 
to  the  touch  and  becomes  red  and  shiny.  There  is  often  con- 
siderable fever.    After  a  few  hours  the  intensity  of  the  seizure 


534   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

abates,  only  to  recur  again  with  renewed  violence  early  the 
next  morning,  these  remissions  and  recurrences  taking  place 
for  six  or  eight  days,  when  the  attack  subsides.  In  patients 
with  chronic  gout  many  joints  are  stiffened  and  detormed  as 
a  result  of  repeated  attacks.  Chalk-stones  form,  and  the  skin 
above  them  may  ulcerate.  Such  patients  are  chronic  dys- 
peptics, have  high-tension  pulses,  their  hearts  are  hyper- 
trophied,  and  their  urine  contains  albumin  and  casts. 

The  trcatinenl  of  gouty  arthritis  belongs  to  the  physician, 
and  not  to  the  surgeon,  although  to  the  latter  the  symptoms 
of  the  disease  should  be  known,  so  that  it  may  be  diagnosti- 
cated from  other  maladies. 

Osteo -arthritis  (Rheumatoid  Arthritis ;  Arthritis  Defor- 
mans; Rheumatic  Gout;  Paget's  Disease). — In  this  disease, 
which  is  not  a  combination  of  gout  and  rheumatism,  the 
synovial  membrane  and  cartilages  are  affected,  the  peri-artic- 
ular structures  are  involved,  and  masses  of  new  bone  are 
formed. 

Osteo-arthritis  has,  as  John  K.  Mitchell  pointed  out,  a 
probable  nervous  origin.  It  arises  especially  in  persons 
who  have  been  worried,  driven,  and  harassed.  There  is  apt 
to  be  muscular  atrophy;  trophic  lesions  of  the  hair  and 
nails  are  likely  to  appear,  and  the  symptoms  are  disposed  to 
be  symmetrical.  The  causative  lesion  has  not  been  de- 
termined. The  disease  is  commoner  in  women  than  in 
men.  The  greatest  liability  exists  between  the  ages  of 
twenty  and  thirty,  but  children  may  acquire  the  disease,  and 
it  may  also  be  developed  in  people  beyond  middle  life.  Apes 
in  captivity  may  develop  it.  Arthritis  deformans  may  attack 
the  rich  or  the  poor;  it  does  not  result  from  gout,  nor  does 
it  often  follow  rheumatism;  it  is  not  caused  by  damp  and 
cold;  and  only  in  rare  cases  does  it  arise  after  traumatism 
of  a  joint. 

Osteo-arthritis  differs  from  gout  in  the  entire  absence 
of  urate  deposit,  and  it  differs  from  chronic  rheumatism  in 
the  extensive  alterations  in  the  joint-structures.  The 
changes  begin  in  the  cartilage;  the  cartilage-cells  multiply, 
the  intercellular  substance  degenerates,  the  pressure  of  the 
bone  causes  thinning,  and  at  length  the  cartilage  is  entirely 
destroyed  and  the  bone  is  exposed.  The  exposed  bone  is 
altered  in  shape,  is  hardened,  and  is  worn  away  in  the  cen- 
ter, the  periphery  increasing  in  thickness  by  ossific  deposit; 
the  center  deepening  by  absorption.  The  margins  are  not 
only  thickened,  but  are  bulged  and  lengthened  by  deposit. 
The  fringes  of  the  synovial  membrane  hypertrophy  and  mul- 


TCBERCi'LOS/S   OF  SPECIAL  JOIXTS.  535 

tiply,  and  some  of  them  are  apt  to  break  off  (loose  carti- 
lages). The  capsule  and  the  ligaments  of  the  joint,  as  a  rule, 
become  fibrous  and  contract ;  but  they  may  soften,  relax,  and 
permit  of  dislocation.  The  joint  usually  contains  no  effusion, 
but  in  some  cases  there  is  great  effusion  (hydrarthrosis).  The 
tendons  about  the  joint  ma}'  become  fibrous  and  contracted, 
they  may  ossify,  they  may  be  separated  from  the  bone,  or 
they  may  be  destroyed  entirely.  Deformity  is  marked  and 
motion  is  limited.  The  fingers,  when  involved,  show  nodules 
on  the  sides  of  the  joints  (Heberden's  nodules).  The  ver- 
tebrae may  be  involved.  Almost  all  the  joints  may  suffer. 
Suppuration  does  not  occur. 

SyuiptODis. — Charcot  divides  osteo-arthritis  into  three 
forms,  and  gives  their  symptoms,  as  follows : 

( i)  Heberden's  nodosities,  which  condition  is  commoner  in 
women  than  in  men,  comes  on  between  the  ages  of  thirt}^ 
and  forty,  and  is  especialh*  common  in  neurotic  subjects. 
The  interphalangeal  joints  become  the  victims  of  attacks  of 
moderate  swelling  and  of  some  tenderness,  which  attacks 
are  not  severe,  but  recur  again  and  again.  After  a  time 
small  hard  swellings  (nodosities)  appear  upon  the  sides  of 
the  dorsal  surfaces  of  the  second  and  third  phalanges,  remain 
permanently,  and  slowh' increase  in  size.  The  joints  become 
stiff  and  creak  on  movement,  the  cartilages  are  destroyed, 
and  contractions  and  rigidit}-  develop,  but  there  is  no  fever 
and  the  larger  joints  are  not  involved.  The  malady  is 
incurable. 

(2)  Progressive  rhemnatie  gout,  which  ma}'  be  acute  or 
chronic.  The  aente  form  begins  as  does  rheumatic  fever. 
There  are  moderate  fever  and  swelling,  without  redness,  of 
a  number  of  joints,  of  bursse,  and  of  tendon-sheaths ;  the 
joints  are  stiff  and  crepitate,  and  are  apt  to  be  symmetric- 
alh'  involved;  muscular  atroph}'  begins  earl}-  and  rapidly 
becomes  decided;  pain  is  slight.  This  acute  form  is  apt  to 
arise  in  }-oung  women  after  pregnane}*,  but  is  not  unusual 
at  the  climacteric  and  in  children.  Anemia  always  exists. 
The  case  is  apt  to  advance  progressiveh'  until  a  number  of 
joints  are  firmh'  locked,  when  it  ma}'  become  stationary. 
Another  pregnane}'  v\ill  develop  anew  the  acute  symptoms. 
In  the  cJironic  form  swelling  and  pain  on  movement  are 
noted  in  certain  joints.  The  invoh'ement  is  apt  to  be  sym- 
metrical. Attacks  of  swelling  and  pain  alternate  with  periods 
of  quiescence,  but  the  disease  does  not  cease  its  advance. 
Articulation  after  articulation  is  attacked  b}-^  the  malady 
until  almost  all  the  joints  are  involved;  deformit}'  and  stiff- 


536    DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS. 

ness   become  pronounced,   and   pain    may   or    may  not    be 
severe.     There  is  no  fever.     Muscular  atrophy  is  marked. 

(3)  Partial  rJicujiiatic  gout  attacks  one  articulation,  and  it 
is  most  often  met  with  in  old  men.  It  may  fix  itself  on  the 
vertebral  column,  on  the  knee,  on  the  shoulder,  on  the 
elbow,  or  on  the  hip.  The  joint  grates,  and  becomes  stiff, 
swollen,  and  deformed;  the  muscles  atrophy;  there  is  usually 
pain,  but  fever  is  absent. 

Osteo-arthritis  or  partial  rheumatic  gout  of  the  hip-joint 
rarely  occurs  before  the  age  of  forty-five,  but  is  occasionally, 
though  very  rarely,  met  with  in  persons  under  twenty-five. 
If  the  disease  arises  in  an  elderly  person,  it  is  often  called 
morbus  coxae  senilis.  In  some  cases  only  the  hip-joint  is 
attacked,  in  many  cases  other  joints  are  also  diseased. 
Osteo-arthritis  of  the  hip  may  follow  an  injury.  Usually 
the  disease  is  unconnected  with  traumatism,  begins  very 
gradually,  and  advances  slowly.  There  is  pain  in  and  about 
the  joint,  often  mistaken  for  sciatica,  and  there  is  increasing 
stiffness.  The  pain  and  stiffness  are  worse  when  the  patient 
first  moves  after  resting.  Lameness  becomes  noticeable, 
and  grating  can  be  detected  in  and  about  the  joint.  The 
symptoms  get  gradually  worse,  although  at  times  they  may 
seem  to  improve  for  a  brief  period.  The  lameness  and  the 
stiffness  are  greatly  aggravated,  and  the  pain  becomes  very 
severe,  even  when  at  rest.  Shortening  takes  place,  the  tro- 
chanter ascends  above  Nelaton's  line,  the  limb  is  usually 
abducted,  but  in  very  rare  cases  is  adducted,  and  finally 
ankylosis  occurs. 

Partial  rheumatic  gout  of  the  vertebral  articulations  caus- 
ing fixation  is  called  "spondylitis  deformans"  (p.  584). 

Treatment. — Osteo-arthritis  cannot  be  cured,  but  in  some 
cases  it  remains  stationary  for  many  years.  Treat  the  anemia 
by  iron,  arsenic,  nourishing  food,  and  have  the  patient  be 
out  in  the  fresh  air  as  much  as  possible.  Debility  is  met  by 
the  administration  of  strychnin.  Hot  baths  of  mineral  water 
do  good.  It  is  claimed  that  the  hot-air  apparatus  is  of  ser- 
vice. Douches  improve  these  cases,  but  electricity  is  useless. 
Counterirritants  do  no  good.  Massage  retards  the  progress 
of  the  case,  relieves  the  pain,  aids  in  the  absorption  of  effu- 
sion, and  delays  fixation.  During  an  acute  exacerbation  the 
joint  should  be  put  at  rest  for  a  time  and  evaporating  lotions 
applied.  In  an  exacerbation  in  disease  of  the  hip  the  patient 
should  be  put  to  bed  and  have  extension  applied.  The  patient 
is  unfortunately  liable  to  develop  the  opium-habit.  If  dropsy 
of  a  joint  arises,  try  compression  with  a  Martin  bandage, 


TUBERCULOSIS   OF  SPECIAL  JOINTS.  537 

and,  if  this  fails,  aspirate  and  wash  out  the  joint  with  a  2  per 
cent,  solution  of  carbolic  acid.  Patients  with  rheumatic  gout 
do  best  in  a  w^arm,  dry  climate.  Cod-liver  oil  does  Cfood,  as 
it  miproves  nutrition  and  hence  retards  the  progress  of  the 
disease.  Do  not  be  tempted  to  immobilize  the  jomts  beyond 
a  day  or  two :  fixation  only  hastens  ankylosis.  Howard 
Marsh  ^  points  out  that,  as  a  rule,  but  little  good  comes  from 
manipulation.  He  makes  the  following  exceptions :  When 
one  joint  only  is  affected;  when  the  joint  is  very  stiff  but 
not  very  painful ;  when  the  patient  is  in  good  general  health 
and  is  not  beyond  middle  age. 

Charcot's  Disease  (Tabetic  Arthropathy  ;  Charcot's  Joint; 
Neuropathic  Arthritis). — This  condition  is  an  osteo-arthritis 
due  to  trophic  disturbance,  arising  in  a  sufferer  from  loco- 
motor ataxia,  and  is  anatomically  identical  with  osteo-ar- 
thritis, which  was  described  above.  The  knee  is  most  apt  to 
be  attacked,  and  the  hip  suffers  more  often  than  any  joint 
but  the  knee.  The  disease  begins  acutely,  often  as  a  sudden 
effusion,  which  after  a  time  disappears.  Pain  is  slight  or  is 
absent,  there  is  no  constitutional  involvement,  and  the  condi- 
tion is  unconnected  with  injury.  The  bones  and  cartilages 
are  rapidly  destroyed;  fracture  is  apt  to  occur;  the  joint 
creaks  and  grates ;  the  softening  and  relaxation  of  liga- 
ments permit  an  extensive  range  of  movement ;  great  de- 
formity ensues ;  dislocation  is  apt  to  occur ;  muscular  atro- 
phy is  decided;  and  pus  occasionally,  though  very  rarely, 
forms. 

Trcannent. — The  treatment  of  Charcot's  disease  consists 
in  the  wearing  of  an  apparatus  to  sustain  the  joint.  Resec- 
tion is  recommended  by  some,  but  most  surgeons  do  not 
advise  its  performance. 

Osteo-arthropathie  Hypertrophiante  Pneumique 
(Marie's  Disease). — A  condition  associated  with,  and  pos- 
sibly springing  from,  pulmonary  disease,  and  characterized 
by  enlargement  of  joints,  thickening  of  the  finger-ends,  and  the 
formation  of  a  dorsolumbar  kyphosis.  The  joints  are  pain- 
ful, the  skin  undergoes  pigmentation,  and  profuse  perspira- 
tion is  often  present.  The  head  entirely  escapes  in  this 
disease,  which  immunity  marks  a  distinction  from  acromeg- 
aly. 

Hysterical  joint  (Brodie's  joint)  is  a  condition  mostly 
encountered  in  young  women.  The  disease  occurs  most 
commonly  in  the  knee  and  the  hip,  and  often  follows  a  slight 
injury  which   acts   as   an   autosuggestion,  a   latent  hysteria 

*  Diseases  of  the  Joints  a7td  Spine. 


538   DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS. 

being  awakened  into  action  and  localized,  though  severity  of 
the  injury  does  not  determine  the  severity  of  the  symptoms. 
The  disease  may  ensue  upon  a  synovitis  or  an  arthritis,  or 
may  arise  without  apparent  cause.  The  patient  complains  of 
pain  in  and  stiffness  of  the  joint,  resists  passive  motion  strenu- 
ously and  claims  that  it  causes  much  pain.  There  is  occasion- 
ally some  muscular  atrophy  from  want  of  use,  and  the  joint 
is  a  little  swollen.  The  skin  is  hyperesthetic,  and  a  light 
touch  causes  more  pain  than  does  deep  pressure.  The 
muscles  may  be  rigid.  The  joint  may  be  maintained  either 
in  flexion  or  in  extension,  but  it  is  rarely  in  the  exact  degree 
of  flexion  assumed  for  ease  in  a  true  joint-inflammation,  and 
the  position  is  apt  to  be  changed  from  day  to  day  or  from 
hour  to  hour.  The  skin  is  usually  pale  and  cool,  but  may 
be  red  and  hot,  because  of  hyperemia.  A  periodically  de- 
veloped heat  may  be  observed,  especially  at  night,  accom- 
panied apparently  by  much  pain.  The  alleged  pain  in  some 
cases  is  a  neuralgia,  but  in  most  cases  is  a  pain-hallucination. 
There  is  no  effusion  into  the  joint,  and  swelling  does  not 
exist,  although  occasionally  there  is  slight  periarticular 
edema.  In  some  rare  cases  organic  disease  arises  in  a  hys- 
terical joint. 

Hysterical  phenomena  are  seldom  isolated,  but  are  asso- 
ciated with  certain  stigmata  which  may  be  latent.  These 
stigmata  are  concentric  contraction  of  the  visual  fields, 
pharyngeal  anesthesia,  convulsions,  hysterogenic  zones, 
globus  hystericus,  clavicus  hystericus,  zones  of  anesthesia, 
especially  hemianesthesia,  and  hyperesthetic  areas.  Such 
patients  are  predisposed  by  inheritance,  and  have  previously, 
as  a  rule,  had  nervous  troubles.  Hysterical  phenomena,  be 
it  remembered,  lack  regularity  of  evolution,  and  are  pro- 
duced, altered,  or  abolished  by  mental  influences  and  physi- 
cal sensations  which  are  without  effect  in  causing,  modifying, 
or  curing  organic  disease.  The  general  health,  as  a  rule,  is 
good,  but  neurasthenia  may  coexist.  In  examining  these 
patients  the  observer  will  note  that  the  symptoms  disappear 
when  the  attention  is  diverted ;  that  they  are  out  of  all 
proportion  to  the  local  evidences  of  disease ;  that  there  is 
no  sign  of  joint-destruction  ;  and  that  a  light  touch  may 
cause  more  pain  than  does  firm  pressure.  If  the  patient  is 
anesthetized,  perfect  joint-mobility  will  be  found. 

Treatment. — The  treatment  in  hysterical  joints  comprises 
attention  to  the  general  health,  the  employment  of  nourish- 
ing and  easily  digested  food,  the  prevention  of  constipation, 
and  the  administration  of  tonics  if  they  are  needed.     The 


NEURALGIA    OF   THE  JOLYTS.  539 

surgeon  must  dominate  his  patient's  mind  and  make  her  real- 
ize that  he  is  master  of  the  case.  He  is  to  be  an  inexorable 
but  just  ruler — never  a  brutal  or  a  cruel  one.  If  possible, 
send  the  patient  away  from  the  harmful  sympathies  of  her 
home  and  let  her  have  the  rest-treatment  of  \Veir  Mitchell. 
Local  remedies  applied  to  the  joint  do  harm,  as  a  rule,  by 
concentrating  afresh  the  patient's  attention  upon  the  articula- 
tion, although  the  hot  iron  sometimes  does  good.  Sugges- 
tion in  the  hypnotic  state  may  be  tried.  The  use  of  morphin 
should  be  avoided  as  being  the  worst  of  enemies.  Never 
immobilize  the  joint,  and  always  use  massage,  passive 
motions,  and   frictions. 

Neuralgia  of  the  joints  as  an  independent,  isolated 
affection  is  extremely  rare,  though  as  a  complication  of 
other  diseases  it  is  b}'  no  means  uncommon.  The  neuralgia 
is  more  often  outside  of  the  joints  than  in  them,  and  is  espe- 
ciall}-  frequent  in  the  knee  and  the  ankle.  Joint-neuralgia 
may  arise  in  any  person,  but  it  is  more  commonly  present 
in  young  neurotic  females.  The  pain  may  be  persistent,  or 
it  may  occur  in  periodic  storms,  and  it  is  often  associated  with 
neuralgia  in  other  parts.  The  pain  may  be  dull  and  aching, 
but  it  is  more  often  sharp  and  shooting.  Joint-neuralgia  is 
associated  with  tenderness  on  pressure,  soreness  on  motion, 
often  with  transitory-  swelling  without  redness,  and  some- 
times with  numbness  of  the  extremities.  The  diagnosis 
depends  on  the  temperament  of  the  patient,  the  sudden 
onset  of  the  pain,  the  absence  of  constitutional  s}'mptoms, 
and  the  free  mobility  of  the  joint,  especially  under  ether. 
Articular  neuralgia  may  depend  upon  disease  or  injur}'  of 
the  central  nervous  system,  upon  malaria,  s^'philis,  neuras- 
thenia, rheumatism,  gout,  hysteria,  and  neuritis,  and  may  be 
due  to  reflected  irritation,  especially  from  the  ovaries,  the 
uterus,  or  the  rectum. 

Treatment. — The  treatment  to  be  observed  in  joint-neu- 
ralgia is  to  maintain  the  general  health.  Examine  for  a  pos- 
sible exciting  cause,  and,  if  found,  remove  it.  Give  a  long 
course  of  iron,  quinin,  and  strychnin  or  arsenic.  In  rheu- 
matic or  gouty  subjects  administer  suitable  drugs  and  insist 
upon  the  use  of  a  proper  diet.  During  the  attack  use  phe- 
nacetin.  Morphin  must  occasionally  be  given  in  severe 
cases,  but  be  careful  of  it,  and  never  tell  the  patients  they 
are  taking  it,  as  there  is  a  possibility  of  their  forming  the 
opium-habit.  Locally,  employ  frictions,  ointment  of  aconite, 
heat,  and  keep  upon  the  part  a  piece  of  flannel  soaked  in  a 
mixture  of  soap-linament,  laudanum,  and  chloroform  (Gross). 


540   DISEASES  AND   INJURIES    OE  BONES  AND  JOINTS. 

Never  allow  the  joint  to  stiffen  ;  any  tendency  to  stiffness 
should  be  met  by  daily  massage,  frictions,  passive  motion, 
and  hot  and  cold  douches.  In  some  rare  cases  nerve- 
stretching  or  neurectomy  becomes  necessary'. 

Articular  Wounds  and  Injuries. — A  penetrating 
wound  is  very  serious,  and  it  may  be  due  to  a  compound 
fracture,  to  a  compound  dislocation,  to  a  gunshot-wound,  or 
to  a  stab.  If  a  bursa  near  a  joint  be  injured,  secondary 
penetration  may  occur  as  a  result  of  suppuration.  In  a 
penetrating  wound,  besides  pain,  hemorrhage,  and  swell- 
ing, there  is  a  flow  of  synovial  fluid.  A  small  amount  of 
synovia  flows  from  an  injured  bursa,  a  large  amount  from  an 
open  joint. 

Treatment. — If  a  joint  is  opened  aseptically  (as  when  in- 
cised by  the  surgeon),  the  wound  heals  nicely  under  rest  and 
antisepsis.  If  a  joint  is  opened  by  a  septic  body,  suppu- 
rative arthritis  is  apt  to  arise,  and  the  surgeon  endeavors  to 
prevent  it  by  asepticizing  the  surface,  irrigating  the  joint, 
draining,  applying  antiseptic  dressing,  and  securing  rest. 
Normal  salt  solution  is  the  best  agent  for  irrigation,  as  it 
does  not  injure  joint-endothelium.  Active  antiseptics  are  apt 
to  lessen  tissue-resistance,  and  thus  may  actually  favor  in- 
fection. In  gunshot-wounds,  if  antisepsis  is  not  employed, 
suppuration  is  inevitable  ;  hence  military  surgeons  in  the  past, 
as  a  rule,  have  advocated  amputation  or  excision  in  gunshot- 
splinterings  of  large  joints.  In  these  injuries  the  surface  is 
sterilized,  the  wound  is  enlarged,  the  finger  is  introduced  to 
discover  and  remove  foreign  bodies,  through-and-through 
drainage  is  secured,  a  tube  is  inserted,  the  joint  is  irrigated, 
antiseptic  dressings  are  applied,  and  the  extremity  is  placed 
upon  a  splint.  Very  severe  cases  demand  resection  or  even 
amputation.  Ankylosis,  more  or  less  complete,  follows  a 
gunshot-wound  of  a  joint.  If  the  joint  suppurates,  the 
drainage  must  be  made  more  free,  sinuses  must  be  slit  up 
and  packed,  sloughs  must  be  cut  away,  dead  bone  must  be 
gouged  out,  and  the  patient  must  be  placed  upon  a  stimu- 
lant and  tonic  plan  of  treatment.  The  above  remarks  do  not 
apply  to  wounds  inflicted  with  the  modern  military  projectile. 
Such  wounds  are  not  of  necessity  infected,  and  recovery  may 
be  prompt  and  uneventful  if  the  surface  is  sterilized  and  anti- 
septic dressings  and  splints  are  applied. 

Sprains. — A  sprain  is  a  joint-wrench  due  to  a  sudden  twist 
or  traction,  the  ligaments  being  pulled  upon  or  lacerated  and 
the  surrounding  parts  being  more  or  less  damaged.  A  sprain 
is  often  a  self-reduced  dislocation  (Douglas  Graham).     The 


sr/^A/xs.  541 

joints  most  liable  to  sprains  are  the  knee,  the  elbow,  and  the 
ankle.  The  smaller  joints  are  also  often  sprained,  but  the 
ball-and-socket  joints  are  infrequenth^  sprained,  their  normal 
range  of  free  movement  saving  them ;  they  do  occasionally 
suffer  severely,  however,  as  a  result  of  abduction.  In  a  bad 
sprain  the  ligaments  are  torn  ;  the  synovial  membrane  is  con- 
tused or  crushed  ;  cartilages  are  loosened  or  separated;  hem- 
orrhage takes  place  into  and  about  the  joint;  muscles  and 
tendons  are  stretched,  displaced,  or  lacerated ;  vessels  and 
nerves  are  damaged ;  the  skin  is  often  contused ;  and  por- 
tions of  bone  or  cartilage  may  be  detached  from  their  proper 
habitat,  though  still  adhering  to  a  ligament  or  tendon 
(sprain-fractures).  Sprains  are  commonest  in  young  persons 
and  in  adults  with  weak  muscles.  They  happen  from  sudden 
twists  and  movements  when  the  muscles  are  relaxed.  A 
large  part  of  the  support  of  joints  comes  from  muscles,  and 
when  they  are  suddenly  caught  unawares  they  do  not  prop- 
erly support  the  joint,  and  a  sprain  results.  A  joint  once 
sprained  is  ver}'  liable  to  a  repetition  of  the  damage  from 
slight  force.  Sprains  are  common  in  a  limb  with  weak 
muscles,  in  a  deformed  extremit}"  in  which  the  muscles  act 
in  unnatural  lines,  and  in  a  joint  with  relaxed  ligaments. 

Symptoms. — There  is  severe  pain  in  the  joint,  accom- 
panied by  general  weakness.  Xausea,  \omiting,  and  even 
syncope  may  occur.  There  is  impairment  or  loss  of  ability 
to  move  the  joint.  The  above-described  condition  is  suc- 
ceeded by  a  season  of  relief  from  pain  while  at  rest,  numb- 
ness being  complained  of,  and  pain  on  motion  being  severe. 
Swelling  arises  ver}-  early  if  much  blood  is  effused.  In  any 
case  swelling  begins  in  a  few  hours.  Extensive  effusion,  by 
separating  joint-surfaces,  produces  slight  lengthening  of  the 
limb.  Movements  of  the  joint  become  difficult  or  impos- 
sible ;  the  tear  in  the  ligament  may  sometimes  be  distinctly 
detected  by  the  examining  fingers ;  pain  and  tenderness 
become  intense ;  joint-crepitus  will  be  manifested ;  and  in  a 
day  or  two  discoloration  becomes  marked.  Moullin  and 
others  have  pointed  out  that  when  a  muscle  is  strained  the 
skin  above  it  becomes  sensitive,  especially  at  tendinous  in- 
sertions over  joints.  As  muscles  are  invariably  strained 
when  a  joint  is  sprained,  there  is  always  some  cutaneous 
tenderness.  There  is  also  tenderness  over  a  sprained  joint 
due  to  capsular  injur}",  bands  of  adhesions,  etc.  Tenderness 
is  apt  to  arise  at  certain  reasonably  fixed  points  :  in  a  hip- 
joint  injur}'  it  is  found  behind  the  great  trochanter,  in  a 
knee-joint  injuiy  b}-  the  side  of  the  patella,  in  an  ankle-joint 


542    DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS. 

injury  to  the  inner  side  of  the  external  malleolus  (Gulp). 
When  the  vertebral  articulations  are  sprained  the  muscles 
of  the  back  are  rigid,  the  skin  is  often  sensitive,  pain  may  be 
awakened  by  pressure  or  by  certain  movements,  but  there  is 
no  sign  of  cord  injury  in  an  uncomplicated  case. 

Diag-nosis  and  Prognosis. — Sprain-fractures  can  be  diag- 
nosticated with  certainty  only  by  the  ,t'-rays.  In  the  diag- 
nosis of  a  sprain,  fracture  and  dislocation  must  be  consid- 
ered. In  fracture,  crepitus  and  mobility  exist ;  in  dislocation, 
rigidity.  The  diagnosis  of  sprain  should  be  made  by  a  con- 
sideration of  the  joint  involved,  of  the  age,  of  the  nature  of 
the  force,  of  the  length  of  the  limb,  of  the  fact  that  the 
patient  could  use  the  joint  for  at  least  a  short  time  after  the 
accident,  and  of  the  local  feel  and  movements  of  the  part. 
In  some  cases  examine  under  ether,  in  some  apply  the  .f-rays. 
Injuries  about  the  ankle  which  we  would  have  formerly  re- 
garded as  sprains,  are  often  shown  by  the  ;i'-rays  to  be  fract- 
ures. The  prognosis  depends  on  the  size  of  the  joint,  on 
the  extent  of  laceration,  on  the  amount  of  intra-articular 
hemorrhage,  and  on  the  age  of  the  patient.  The  danger  is 
ankylosis.  In  rare  cases  after  a  sprain  of  the  hip-joint  osteo- 
arthritis arises.  In  some  few  cases  after  a  sprain  of  the  hip 
the  head  of  the  bone  undergoes  absorption. 

Treatment, — In  a  mild  sprain  apply  at  once  a  silicate  or 
plaster  dressing.  The  first  indication  after  the  infliction  of 
a  severe  sprain  is  to  arrest  hemorrhage  and  limit  inflamma- 
tion. For  the  first  io.^  hours  apply  pressure  and  an  ice-bag. 
Wrap  the  joint  in  absorbent  cotton  wet  with  iced  water,  apply 
a  wet  gauze  bandage,  and  put  on  an  ice-bag.  After  some 
hours  place  the  extremity  upon  a  splint  and  to  the  joint 
apply  flannel  kept  wet  with  lead-water  and  laudanum,  iced 
water,  tincture  of  arnica,  alcohol  and  water,  or  a  solution  of 
chlorid  of  ammonium.  These  evaporating  lotions  produce 
cold.  Instead  of  them,  an  ice-bag  may  be  used  for  a  day  or 
two.  Leeches  around  the  joint  do  good.  Constitutionally, 
employ  the  remedies  for  inflammation.  Morphin  or  Dover's 
powder  is  given  for  the  pain.  Judicious  bandaging  limits  the 
swelling. 

After  a  day  or  two,  if  the  symptoms  continue  or  if  they 
grow  worse,  use  hot  fomentations,  the  hot-water  bag,  plunge 
the  extremity  frequently  in  very  hot  water,  or  apply  heat  by 
Leiter's  tubes.  When  the  acute  symptoms  begin  to  subside, 
rub  stimulating  liniments  upon  the  joint  once  or  twice  a  day 
and  employ  firm  compression  by  means  of  a  bandage  of 
flannel    or    rubber.     Frictions    should    be    made    from    the 


ANA'YLOS/S.  543 

periphery'  toward  the  body.  Many  cases  do  well  at  this 
stage  under  the  local  use  of  ichthyol  and  lanolin  (50  per 
cent.),  tincture  of  iodin,  or  blue  ointment.  Later  in  the  case 
use  hot  and  cold  douches,  massage,  frictions,  passive  motion, 
and  the  bandage.  Passive  motion  is  begun  a  day  or  so  after 
swelling  ceases.  If  massage  causes  the  swelling  to  return, 
abandon  it  for  several  days  and  then  try  it  again.  Blisters 
are  used  when  tender  spots  persist  and  stiffness  is  manifest. 
If  stiffness  becomes  marked,  move  the  joint  forcibly.  Give 
iodid  of  potassium  and  tonics  internally,  and  insist  on  open- 
air  exercise.  If  the  person  is  gouty  or  rheumatic,  use  appro- 
priate remedies.  Van  Arsdale  treats  sprains  by  massage 
almost  from  the  start.  Gibney  treats  them  by  strapping 
wdth  adhesive  plaster.  Many  sprains  may  be  put  up  in  an 
immovable  dressing  the  first  day  or  two  after  the  accident. 
If  the  joint  contains  much  blood,  aspiration  should  be  prac- 
tised before  the  dressing  is  applied. 

The  hot-air  oven  is  a  ver\-  valuable  method  for  treating 
recent  sprains,  and  the  swelling,  pain,  and  stiffness  which 
follow  sprains,  of  the  extremities.  The  sprained  extremity 
is  placed  in  an  oven,  and  the  joint  is  subjected  to  heat 
for  an  hour.  The  next  day  the  treatment  is  repeated,  and 
on  as  many  subsequent  days  as  may  be  necessan,'.  In  an 
acute  sprain  the  pain  often  disappears  during  the  first  appli- 
cation of  heat.  In  the  intervals  between  the  use  of  the  oven 
the  extremit}'  should  be  at  rest  upon  a  splint. 

Ankylosis. — When  a  joint-inflammation  eventuates  in 
the  formation  of  new  tissue  in  and  about  the  joint  contraction 
of  this  tissue  limits  or  destroys  joint-mobility,  producing  the 
condition  known  as  "  ankylosis."  Ankylosis  may  be  com- 
plete (bony)  or  incomplete  (fibrous) ;  it  may  arise  from  con- 
tractures in  the  joint  (true  or  intra-articular  ankylosis)  or 
from  contractures  in  the  structures  external  to  the  joint  (false 
or  extra-articular  ank}'losis). 

True  or  intra-articular  ankylosis  ma\'  arise  from  any 
cause  which  produces  joint-inflammation  with  formation  of 
new  tissue,  and  may  be  due  to  vrounds,  contusions,  sprains, 
dislocations,  fractures  in  or  near  a  joint,  movable  bodies  in  a 
joint,  tubercle,  gout,  rheumatism,  or  syphilis.  Immobiliza- 
tion of  a  healthy  joint  may  cause  partial  anky'losis,  though 
this  has  been  denied.  Even  a  proper  immobilization  of  a 
healthy  joint  will,  if  prolonged,  cause  muscular  atrophy,  but 
the  weakness  and  stiffness  will  pass  away  entirel}-  under 
the  influence  of  proper  treatment.  Firm  immobilization 
with  pressure   may  produce  disastrous    results.     Dr.  O.  \V. 


544   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

Phelps'  points  out  that  experiments  made  by  himself  in 
association  with  Dr.  W.  Oilman  Thompson  and  Dr.  J.  C. 
Cardwell  show  that  immobilization  of  a  normal  joint  will 
not  produce  ankylosis  in  five  months,  and  that  when  a 
healthy  joint  becomes  ankylosed,  it  is  due  to  some  patho- 
logical cause.  Improper  immobilization  may  produce  and 
maintain  intra-articular  pressure,  and  such  pressure  may 
destroy  the  head  of  the  bone  and  the  socket,  and  ankylosis 
will  result.  Further,  Phelps  shows  that  muscular  atrophy 
is  sure  to  follow  prolonged  immobilization.  Ankylosis  is 
more  apt  to  take  place  in  a  hinge-joint  than  in  a  ball-and- 
socket  joint.  In  ankylosis  from  a  general  cause  (as  rheu- 
matic gout)  many  joints  are  apt  to  suffer.  Ankylosis  may  be 
due  to  fibrous  tissue,  and  is  then  usually  partial ;  it  may  be 
due  to  chondrification  of  fibrous  tissue,  and  is  then  incom- 
plete ;  it  may  be  due  to  ossification  of  fibrous  tissue,  and  is 
then  complete,  the  joint  being  entirely  immobile  (osseous  or 
bony  ankylosis).  The  entire  joint  may  be  converted  into 
bone.  Only  one  small  joint-surface  may  contain  adhesions 
(limited  adhesions),  or  the  entire  joint-surface  may  be  bound 
up  in  them  (diffused  adhesions).  In  what  is  known  as 
spondylitis  deformans  there  is  bony  ankylosis  of  the  vertebrae. 
Arthritis  ossificans  is  a  progressive  bony  ankylosis  in  which 
numerous  joints  are  involved,  and  are  finally  completely 
obliterated.  It  is  essentially  the  same  disease  as  spondylitis 
ossificans  and  is  an  ossifying  arthritis.^ 

Fibrous  ankylosis  may  follow  aseptic  inflammation ;  bony 
ankylosis  is  apt  to  follow  infections.  Though  slight  motion 
is  usually  possible  in  fibrous  ankylosis,  in  some  cases  it  may 
be  impossible.  A  joint  immovable  from  fibrous  ankylosis  is 
distinguished  from  a  joint  immovable  from  bony  ankylosis 
by  the  fact  that  in  the  former  attempts  at  motion  are  pro- 
ductive of  pain,  and  subsequently  of  inflammation.  The 
incapacity  resulting  from  ankylosis  is  due,  first,  to  the  im- 
pairment or  destruction  of  joint-function,  and,  secondly,  to 
the  fixation  at  an  inconvenient  angle  (a  fixed  flexed  knee  is 
worse  than  a  fixed  extended  knee ;  a  fixed  extended  elbow 
is  worse  than  a  fixed  partly  flexed  elbow). 

Treatment. — The  effort  should  always  be  made  to  prevent 
ankylosis  by  treating  carefully  any  joint-inflammation  and 
by  beginning  passive  motion  and  massage  at  the  proper 
time.     To  limit  inflammation  is  to  prevent  ankylosis.     An 

^  Railway  Suro-eon,  July  26,  1898. 

^  See  Dr.  Joseph  Griffith,  in  Jour,  oj  Pathology  and  Bacteriology,  for  Decem- 
ber, 1896,  and  March  and  June,  1897. 


ANKYLOSIS.  545 

inflammatory  exudate  exists  in  and  about  the  tendons 
and  ligaments,  and  even  in  the  joint.  Early  massage  and 
gentle  movements  remove  this  exudate  before  it  is  organized, 
and  if  organization  of  the  exudate  does  not  occur,  ankylosis 
will  not  follow  the  injury  or  disease.  In  an  acutely  inflamed 
joint,  howev^er,  passive  motions  must  not  be  made,  the  part 
is  kept  at  rest  until  acute  symptoms  subside,  but  gentle  mas- 
sage can  be  used  daily.  When  fibrous  ankylosis  arises  it 
may  be  improved  or  cured  by  the  use  of  the  hot-air  oven, 
passiv^e  motion,  active  movements,  massage,  frictions  with 
stimulating  liniments,  inunctions  of  ichthyol  or  mercurial 
ointment,  hot  and  cold  douches,  and  electricity.  Some 
cases  may  be  straightened  out  slowly  by  screw-splints  or 
by  weights  and  pulleys.  Fibrous  ankylosis  of  the  elbow 
is  best  treated  by  using  the  joint.  Fibrous  ankylosis  is 
often  corrected  by  forcible  straightening.  If  the  tendons 
are  much  contracted,  tenotomy  should  be  performed  two 
or  three  days  before  forcible  straightening  is  attempted. 
Before  straightening  forcibly  always  administer  an  anesthetic. 
Suppose  a  case  of  ankylosis  of  the  knee :  administer  ether, 
put  the  patient  upon  his  back,  bring  the  leg  over  the  end  of 
the  operating-table,  grasp  the  ankle  with  one  hand  and  the 
lower  portion  of  the  leg  with  the  other  hand,  and  make 
strong,  steady  movements  of  flexion  and  extension  until  the 
limb  can  be  straightened.  The  adhesion  will  be  felt  to 
break,  the  snapping  often  being  audible.  At  once  apply  a 
plaster-of-Paris  dressing  to  the  extended  extremity,  and 
keep  the  limb  immobile  for  two  weeks.  At  the  end  of  this 
period  remove  the  plaster  and  begin  massage  and  passive 
movements,  and,  if  reaction  is  not  great,  soon  advise  active 
movements.  This  procedure  is  not  free  from  danger. 
Vessels  may  be  ruptured,  nerves  may  be  torn,  skin  and 
fascia  may  be  lacerated,  suppuration  may  ensue  from  the 
admission  into  the  joint  of  encapsuled  cocci,  or  of  organisms 
in  the  blood  which  find  in  this  area  a  point  of  least  resistance. 
Because  of  the  danger  of  opening  up  depots  of  encapsuled 
bacilli  and  cocci,  do  not  forcibly  break  up  an  ankylosis  that 
results  from  a  tubercular  or  aseptic  arthritis,  but  use  gradual 
extension  by  weights  or  by  screw-splints.  Ankylosis  of  the 
knee  following  fracture  of  the  patella  is  almost  sure  to  recur 
after  forcible  breaking  up.  The  best  treatment  for  knee- 
ankylosis  is  use  of  the  joint.  In  bony  ankylosis  of  any  joint 
other  than  the  elbow-joint  do  nothing  if  the  joint  is  in  a 
useful  position.  If  the  joint  is  firmly  fixed  in  an  unfortunate 
position,  resort  to  excision  or  an  osteotomy.     In  the  elbow 

35 


546   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

excision  should  be  performed,  no  matter  what  the  position, 
in  the  hope  of  obtaining  a  movable  joint.  In  ankylosis  of  the 
jaw  surgeons  formerly  endeavored  to  remedy  the  condition 
by  wedging  the  jaws  apart  with  a  mouth-gag,  and  after- 
ward inserting  boxwood  plugs  at  frequent  intervals.  This 
method  is  invariably  a  failure.^  Esmarch's  operation  is 
sometimes  curative  (removal  of  a  wedge-shaped  piece  of 
bone).  Some  operators  excise  the  condyle  and  a  por- 
tion of  the  neck.  Swain  advocates  sawing  the  bone  at 
the  angle. 

False  or  Extra-articular  Ankylosis. — In  this  condition 
the  joint  is  intact,  but  the  contractures  are  in  surrounding 
parts.  The  causes  are  muscular,  fascial,  and  tendinous  con- 
tractures, cicatrices  (especially  from  burns),  deposits  of  bone, 
muscular  paralysis,  tumors,  and  aneurysm.  Contractions  of 
muscles  or  tendons  may  be  due  to  gout,  rheumatism,  injury, 
thecitis,  fractures,  and  dislocations.  False  ankylosis  is  seen 
in  club-foot  and  in  Dupuytren's  contraction. 

Treatme7it. — The  treatment  of  false  ankylosis  depends 
upon  the  cause.  Recently  contracted  muscles  or  tendons 
require  motion,  massage,  frictions  with  stimulating  liniments, 
hot  and  cold  douches,  and  the  use  of  the  hot-air  apparatus. 
Old  contractions  require  division.  Whenever  possible,  excise 
a  cicatrix  that  causes  false  ankylosis,  and  fill  the  gap  with 
good  tissue.  Bony  deposits  are  gouged  away  and  tumors 
are  removed.  Contractures  in  cases  of  paralysis  require 
electricity,  passive  motion, frictions  with  stimulating  liniments, 
the  hot-air  bath,  and  general  treatment. 

I/Oose  Bodies  in  Joints  (Floating  Cartilages). — The 
knee  is  the  joint  oftenest  affected.  These  bodies  may  be  free 
or  each  may  have  a  stalk  or  pedicle  ;  they  may  move  about 
and  occasionally  block  the  joint,  or  may  lie  quietly  in  a  joint- 
recess  or  diverticulum.  They  may  be  single  or  multiple,  flat 
or  ovoid,  smooth  or  irregular,  as  small  as  peas  or  as  large  as 
plums,  and  may  be  composed  of  fibrous  tissue,  of  bone,  or  of 
cartilage.  There  are  numerous  different  modes  of  origin  of 
these  bodies,  many  being  "  detached  ecchondroses  or  pieces 
of  hyaline  cartilage  hanging  by  narrow  pedicles  "  (J.  Bland 
Sutton),  and  they  result  from  enlargement  and  chondrifica- 
tion  of  the  villi  of  the  synovial  membrane.  Some  loose 
bodies  are  broken-off  osteophytes ;  some  arise  from  blood- 
clots  ;  some  by  projection  or  herniation  of  the  synovial 
membrane,  which  protrusion  is  broken  off;  others  are  de- 
tached fringes  of  tubercular  synovial  membrane.     Trauma- 

^  Swain,  in  Lancet,  1894,  vol.  ii.  p.  187. 


TRAUMATIC  DISLOCATIONS.  547 

tism  is  the  usual  exciting  cause.  Loose  cartilages  are  com- 
monest in  adult  men. 

Symptoms. — Many  small  bodies  give  rise  to  no  symptoms 
other  than  those  of  synovitis.  A  large  body  produces  pain 
and  interferes  with  joint-function.  The  joint  is  weak  and 
a  little  swollen,  and  the  patient  can  feel  the  body  and  often 
can  push  it  into  a  superficial  area  of  the  joint,  where  it  may 
be  felt  by  the  surgeon.  From  time  to  time  the  body  may 
get  caught,  thus  suddenly  locking  the  joint  and  producing 
intense  and  sickening  pain,  extension  and  flexion  being  im- 
possible until  the  body  slips  out.  This  accident  is  followed 
by  inflammation  and  effusion. 

Treatment. — To  relieve  locking,  employ  forced  flexion  and 
sudden  extension.  Cure  can  be  obtained  only  by  operation. 
Asepticize  with  the  utmost  care.  Let  the  patient  bring  the 
foreign  body  to  a  point  where  it  can  be  felt ;  the  surgeon 
then  fixes  it  with  a  pin  or  holds  it  with  the  fingers,  ether 
being  given  or  cocain  being  used.  The  joint  is  now  opened, 
the  foreign  body  extracted,  and  an  exploration  made  to 
see  that  no  other  bodies  are  present.  The  wound  is 
sutured  and  the  leg  is  placed  upon  a  splint.  Asepsis  must 
be  most  rigid.  The  operation  does  not  cure  the  causative 
lesion,  and  these  bodies  are  apt  to  form  again. 

4.  Luxations  or  Dislocations. 

A  dislocation  is  the  persistent  separation  from  each  other, 
partially  or  completely,  of  two  articular  surfaces.  A  self- 
reduced  dislocation  is  called  a  sprain  (Douglas  Graham). 
There  are  three  forms  of  dislocations  :  (i)  traumatic  ;  (2)  spon- 
taneous or  pathological ;  (3)  congenital. 

I.  Traumatic  dislocations  are  due  to  injury.  They 
are  divided  into — complete  dislocation,  in  which  the  two 
articular  surfaces  are  entirely  separated  and  the  ligaments  are 
torn ;  incomplete  or  partial  dislocation,  in  which  the  two 
articular  surfaces  are  not  completely  separated  and  the  liga- 
ments are  rarely  lacerated  ;  simple  dislocation,  in  which  there 
is  no  wound  leading  from  the  surface  to  the  articulation ; 
compound  dislocation,  in  which  a  wound  leads  from  the  sur- 
face to  the  joint ;  complicated  dislocation,  in  which,  besides 
the  dislocation,  there  is  a  fracture,  extensive  damage  of  the 
soft  parts,  an  opening  which  makes  the  case  compound,  or 
damage  of  a  nerve  or  blood-vessel ;  primitive  dislocation,  in 
which  the  bones  remain  as  originally  displaced ;  secondary 
dislocation,  in  which   the   dislocated   bone   assumes   a   new 


548    DISEASES  AND    INJURIES    OF  BONES  AND  JOINTS. 

position ;  for  instance,  a  subglenoid  luxation  of  the  humerus 
is  primary,  and  it  may  become  secondarily  a  subcoracoid 
luxation  because  of  muscular  contraction  or  attempts  at 
reduction  ;  recent  dislocation,  in  which  the  displaced  bone  is 
not  firmly  fastened  by  tissue-changes  in  its  new  situation, 
and  its  old  socket  is  not  obliterated ;  old  dislocation,  in  which 
the  displaced  bone  is  firmly  fastened  by  tissue-changes  in  its 
new  habitat,  and  the  .  old  socket  is  to  a  great  extent  obliter- 
ated (whether  a  dislocation  is  old  or  new  depends  on  the 
state  of  the  parts  rather  than  on  the  time  which  has  elapsed 
since  the  accident) ;  doable  dislocation,  in  which  correspond- 
ing bones  on  each  side  are  dislocated ;  single  dislocation,  in 
which  only  one  joint  is  dislocated;  unilateral  dislocation,  in 
which  one  articulation  of  one  bone  is  out  of  place;  bilateral 
dislocation,  in  which  symmetrical  articulations  are  dislocated  ; 
and  relapsing  or  habitual  dislocation,  which  recurs  constantly 
from  slight  force  because  of  relaxed  ligaments  or  lack  of 
complete  repair  after  the  ligamentous  rupture  of  a  first  dis- 
location. 

2.  Spontaneous,  Pathological,  or  Consecutive  Dis- 
locations.— Spontaneous  dislocation  arises  from  such  very 
slight  force  that  the  cause  may  not  be  identified,  and  it  acts  on 
a  joint  rendered  lax  by  disease.  It  may  arise  in  the  course 
of  chronic  synovitis,  during  tubercular  joint-disease,  and 
during  rheumatoid  arthritis.  In  typhoid  fever  spontaneous 
dislocation  is  not  uncommon.  The  hip-joint  is  most  often 
the  one  attacked.  The  dislocation  in  typhoid  follows  a  severe 
joint-inflammation,  is  usually  upon  the  dorsum  of  the  ilium, 
and  is  frequently  not  noticed  until  convalescence.  If  a 
typhoid  dislocation  is  seen  early,  reduction  is  easily  effected, 
but  if  seen  late  is  impossible.  The  treatment  for  irreducible 
typhoid  dislocation  is  the  same  as  for  any  other  irreducible 
dislocation.  In  Charcot's  joint  this  form  of  dislocation  con- 
stantly appears.  This  condition  comes  on  in  a  few  hours, 
during  the  progress  of  locomotor  ataxia,  and  is  without  ap- 
parent reason.  The  knee,  the  shoulder,  or  some  other  joint 
becomes  greatly  swollen,  fluid  gathers  in  large  amount,  the 
ligaments  relax,  the  joint  is  destroyed  and  becomes  exces- 
sively mobile,  but  there  is  no  pain,  no  fever,  and  no  sign  of 
inflammation  (p.  537).     In  Charcot's  joint  apply  a  support. 

3.  Congenital  Dislocations. — A  congenital  dislocation 
is  due  to  a  congenital  joint-malformation  which  renders 
it  impossible  for  the  bone  to  maintain  a  normal  position, 
or  is  due  to  external  violence  during  the  period  of  uterine 
gestation.     Congenital  dislocations  should  not  be  confounded 


TRAUMATIC  DISLOCATIOiXS.  549 

with  dislocations  produced  during  delivery.  The  hip  is  the 
joint  most  often  involved.  The  shoulder  suffers  occasionally. 
Lannelongue  maintains  that  congenital  dislocation  of  the  hip 
is  due  to  atrophy  of  the  muscles  and  of  the  acetabulum 
following  spinal-cord  disease.  Verneuil  thinks  the  disloca- 
tion is  paralytic.  Broca  truly  says  that  in  view  of  the  fact 
that  the  head  of  the  bone  is  larger  than  the  cavity  in  which 
it  belongs,  it  is  useless  to  attempt  reduction  b}'  manipulation 
or  extension.  Hofta  and  Lorenz  have  each  devised  an  oper- 
ation for  this  condition  (p.  613).  Congenital  dislocation  of 
the  shoulder  requires  incision,  possibly  excision,  or  the  paring 
down  of  the  head  to  fit  the  glenoid  cavity  (Phelps). 

Traumatic  Dislocations. — In  the  succeeding  pages 
the  traumatic  form  of  dislocations  will  be  particularly  con- 
sidered. 

The  causes  of  traumatic  dislocations  are  divided  into  pre- 
disposing and  exciting. 

Predisposing  causes  are  (i)  Age — dislocations  are  com- 
monest in  middle  life,  the  usual  lesion  of  the  young  being 
green-stick  fracture,  and  that  of  the  old  being  fracture. 
Dislocations  of  the  radius  are  not  uncommon  in  youth. 
(2)  Muscidar  developmeiit — dislocations  being  commonest  in 
those  with  powerful  muscles.  (3)  Sex — males  being  more 
predisposed  than  females,  because  of  their  occupations  and 
muscular  strength.  (4)  Occupation  predisposes  as  a  cause 
according  as  it  demands  the  employment  of  muscular  force, 
as  in  the  carrying  of  burdens.  (5)  Nature  of  the  joint — 
ball-and-socket  joints  being  more  liable  to  luxation  than  are 
ginglymoid  joints,  because  of  their  wide  range  of  motion. 
{G)  Joint-disease  ^x&di\ST^os&s  by  relaxing  the  ligaments.  (7) 
Situation  of  tJie  joint — some  joints  being  more  exposed  to 
injury  than  others. 

Exciting  catises  are  classified  into  (i)  external  violence 
and  (2)  muscular  action.  External  violence  may  be  direct, 
as  when  a  blow  upon  one  of  the  bones  forces  it  directly 
away  from  the  other ;  or  it  may  be  indirect,  as  when  a  blow 
at  a  distant  part  of  a  bone  transmits  force  to  its  end  and 
drives  the  bone  out  of  its  socket.  Muscular  actio?i  is  a 
cause  when  sudden  and  violent  muscular  contraction  occurs 
during  the  maintenance  of  a  position  of  the  joint  which  gives 
the  muscles  full  sway,  and  throws  the  head  of  the  bone 
against  the  weakest  part  of  its  retaining  ligaments. 

Pathological  Conditions. — In  a  recent  complete  trau- 
matic dislocation  the  ligaments  are  damaged,  and  may 
perhaps  show    extensive   laceration,  or    may  show    only   a 


550   DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS. 

button-hole  laceration  through  which  a  bone  projects.  Ex- 
ternal force  produces  much  laceration  and  little  stretching- 
of  the  ligaments ;  muscular  action  produces  little  laceration 
and  much  stretching  of  the  ligaments.  In  some  cases  of 
dislocation  due  to  external  violence  the  structures  about  the 
joint  are  bruised  or  otherwise  damaged;  the  old  socket  is 
filled  with  blood,  and  the  bone  in  its  new  situation  lies  in  a 
bloody  area.  Large  vessels  and  nerves  are  rarely  torn, 
though  they  may  be  compressed. 

If  a  dislocation  is  not  soon  reduced,  inflammation  arises 
in  the  old  joint  and  about  the  displaced  bone,  and  the  whole 
area  is  glued  together,  first  by  coagulated  exudate,  and 
finally  by  fibrous  tissue.  After  a  time,  in  ball-and-socket 
joints,  the  old  socket  fills  with  fibrous  tissue,  contracts, 
becomes  irregular,  and  may  even  be  obliterated ;  the  head 
of  the  dislocated  bone  is  altered  in  shape,  its  cartilage  is  de- 
stoyed  or  converted  into  fibrous  tissue,  and  the  pressure 
of  the  head  of  the  bone  forms  a  hollow  in  its  new  situation, 
which  hollow  becomes  surrounded  by  fibrous  tissue  or  even 
by  bone.  A  new  joint  may  form,  the  surrounding  tissue 
becoming  a  compact  capsule,  and  'a  bursa  forming  between 
the  head  of  the  bone  and  its  new  socket.  In  a  dislocated 
hinge-joint  the  ends  of  the  bone  alter  greatly  in  shape  and 
their  cartilage  is  converted  into  fibrous  tissue.  In  an  unre- 
duced dislocation  the  muscles  shorten  or  lengthen  or 
undergo  atrophy  or  fatty  degeneration,  as  the  case  may  be. 
An  unreduced  dislocation  of  a  ball-and-socket  joint  may 
give  a  fairly  movable  new  joint,  but  an  unreduced  disloca- 
tion of  a   hinge-joint  rarely  allows  of  much  motion. 

General  Symptoms  of  Traumatic  Dislocations. — In 
general,  traumatic  dislocations  are  indicated  {\)hy  pain  of 
a  sickening,  nauseating  character ;  (2)  by  rigidity,  voluntary 
motion  being  impossible  except  to  a  slight  extent  in  the  direc- 
tion of  the  deformity.  (For  instance,  in  dislocation  of  the 
inferior  maxillary  the  jaw  can  be  opened  a  little  more,  but 
it  cannot  be  closed.)  This  rigidity  brings  about  loss  of 
function.  When  the  surgeon  attempts  to  move  the  joint 
he  finds  it  very  rigid ;  (3)  by  change  in  the  shape  of  the  joint 
(as  flattening  of  the  shoulder  after  dislocation  of  the  hume- 
rus) ;  (4)  by  alteration  in  the  mutual  relations  of  bony  promi- 
nences about  a  joint  (as  the  alteration  of  the  relation  between 
the  olecranon  and  humeral  condyles  in  dislocation  of  the 
elbow  backward) ;  (5)  by  feeling  the  displaced  bone  in  its 
new  situation  ;  (6)  by  missing  the  head  of  the  bone  from  its 
proper  situation ;  (7)  by  alteration  in  the  length  of  the  limb 


TRAUMATIC   D/SI.OCATW.YS.  55  I 

(in  dislocation  of  the  femur  into  the  thyroid  foramen  the  limb 
is  lengthened,  but  in  dislocation  onto  the  dorsum  of  the 
ilium  it  is  shortened)  ;  and  (8)  by  alteration  in  the  axis  of 
the  bone  (in  dislocation  upon  the  dorsum  of  the  ilium  the 
axis  of  the  injured  thigh  would,  if  prolonged,  pass  through 
the  lower  third  of  the  sound  thigh) ;  (9)  by  seeing  the  dislo- 
cation with  a  fluoroscope  or  looking  at  a  skiagraph  of  it. 

Diagnosis  of  Traumatic  Dislocations. — A  dislocation 
may  be  mistaken  for  a  fracture.  In  dislocation  there  is 
rigidity,  in  fracture  there  is  preternatural  mobility;  in  dislo- 
cation there  is  no  true  crepitus  (may  get  tendon-  or  joint- 
crepitus),  in  fracture  there  usually  is  crepitus  ;  in  dislocation 
the  deformit}'-  does  not  tend  to  recur  after  reduction,  in 
fracture  it  does  recur  after  extension  is  relaxed.  In  a  sprain 
the  movements  of  the  joint  are  only  limited,  not  abolished, 
by  an  almost  complete  rigidity.  The  change  which  a  sprain 
may  cause  in  the  shape  of  a  joint  is  due  to  effusion  or  to 
bleeding ;  there  is  no  alteration  in  the  relation  of  the  bony 
prominences  to  one  another ;  there  is  no  notable  alteration 
in  the  length  of  the  limb  (a  slight  increase  in  length  may 
arise  from  joint-effusion,  or  the  head  of  the  bone  may  sub- 
sequently be  absorbed,  and  thus  produce  shortening  after 
some  weeks) ;  there  is  no  alteration  in  the  axis  of  the  bone  ; 
the  head  is  not  felt  in  a  new  position,  it  being  found  in  its 
normal  place.  Always  remember  that  a  fracture  may  exist 
with  a  dislocation.  In  any  doubtful  case — in  fact,  in  most 
cases — give  ether,  for  a  dislocation  should  be  reduced  while 
the  patient  is  anesthetized  (except  in  dislocation  of  the  jaw, 
of  the  fingers,  of  the  carpus,  etc.).  In  some  cases  swelling 
renders  the  diagnosis  difficult  or  impossible.  Always  com- 
pare the  injured  joint  with  the  corresponding  joint  of  the 
sound  side.  The  .r-rays  constitute  a  valuable  aid  to  diag- 
nosis. 

Treatment  of  Traumatic  Dislocations. — Rccoit  Simple 
Dislocations. — Reduce  simple  dislocations  under  ether,  as  a 
rule.  Try  manipulation,  a  procedure  which  seeks  to  make 
the  bone  retrace  its  own  pathway.  If  this  procedure 
fails,  employ  extension  and  counter-extension.  If  consid- 
erable force  is  needed,  an  assistant  makes  counter-exten- 
sion, and  the  surgeon  fastens  to  the  extremit\^  a  clove-hitch, 
which  he  ties  about  his  waist,  and  thus  secures  powerful 
extension.  Counter-extension  may  be  obtained  by  bands, 
or,  in  some  instances,  by  the  foot  of  the  surgeon.  The 
clove-hitch  is  used  because  it  will  not  tighten  by  traction, 
a  tightening  band  would  lacerate  the  soft  parts  (Fig.  178). 


552    DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS. 

If  great  power  is  needed,  compound  pulleys  may  be  em- 
ployed, such  as  the  Jarvis  adjuster  or  some  similar  appli- 
ance, but  at  the  present  day  pulleys  are  rarely  used 
(see  page  554).  If  these  means  fail,  cut  down  upon  the 
bone  and  restore  it  to  position  ;  operation  is  much  safer 
than  is  the  application  of  great  force.  After  reducing  a 
dislocation,  immobilize  the  joint  for  a  time,  which  varies 
for  different  joints,  and  for  the  first  few  days  combat  swelling 
and  inflammation  by  rest  of  the  part  and  the  use  of  evapo- 
rating lotions  or  an  ice-bag.  If  there  exists  a  fracture  of  the 
dislocated  bone,  apply  splints  and  then  try  to  reduce  by 
manipulations,  grasping  the  limb  and  the  splints  with  one 
hand  below  and,  if  possible,  with  the  other  hand  above  the 
seat  of  the  fracture.  Allis  believes  that  a  dislocation  can  be 
reduced  even  when  a  fracture  exists.  It  is  possible  to  pull 
the  dislocated  head  down  to  the  joint,  because  a  portion  of 
periosteum  and  possibly  tendinous  material  and  muscle  still 
hold  the  two  fragments  as  a  strap  might  unite  two  sticks. 
The  head  can  be  forced  into  place  by  the  fingers  while  trac- 
tion is  being  made.  If  the  fracture  is  near  the  joint  and  the 
fragments  cannot  be  fixed,  try  to  reduce  the  dislocation,  first 
striving  to  press  the  bone  into  place.  This  attempt  can  be 
greatly  aided  by  traction  upon  the  lower  fragment.  In  some 
cases  with  fracture  reduction  can  be  much  aided  by  making 
a  small  incision,  screwing  a  gimlet  into  the  head  of  the  bone, 
and  using  this  tool  as  a  handle.  McBurney  incises,  drills 
a  hole  in  each  bone,  inserts  hooks  into  them,  and  pulls  the 
dislocated  bone  into  position  (Figs.  112,  113).  When  the 
dislocation  has  been  reduced  the  bone  fragments  are  wired. 

Compound  Traumatic  Dislocations. — The  opening  in  the 
soft  parts  may  be  due  to  external  violence  or  to  projection 
of  a  bone.  Compound  dislocations  are  very  serious.  Hinge- 
joints  are  more  liable  to  these  injuries  than  are  ball-and- 
socket  joints.  Many  cases  require  excision,  some  amputation  ; 
one  that  does  not  demand  excision  or  amputation  should  be 
treated  by  sterilizing  the  parts,  restoring  the  dislocated  bone, 
making  a  counter-opening,  draining,  dressing  antiseptically, 
and  immobilizing.  Considerable  ankylosis  generally  ensues, 
except  sometimes  in  the  small  joints.  It  is  scarcely  ever 
necessary  to  cut  away  any  portion  of  the  protruding  bone 
to  effect  reduction.  If  a  joint  is  badly  splintered,  or  if 
the  soft  parts  are  extensively  damaged,  excise  or  amputate ; 
if  the  main  vessels  or  the  nerves  are  seriously  injured,  or  if 
the  patient  is  so  old  or  so  feeble  that  it  is  perilous  to  force 
him  to  combat  a  long  illness,  amputate. 


SPECIAL    TRAUMATIC  DISLOCATIONS.  553 

Old  Traumatic  Dislocations. — The  problem  always  pre- 
sented in  an  old  dislocation  is,  Shall  reduction  be  tried,  or  shall 
the  bones  be  left  alone  ?  Sir  Astley  Cooper  laid  down  this 
rule  :  "  Do  not  attempt  to  reduce  a  shoulder-dislocation  after 
three  months,  nor  a  hip-dislocation  after  two  months  ;"  but 
this  rule  was  laid  down  before  the  days  of  ether.  Do  not 
select  any  fixed  period  of  time  to  determine  what  action  is 
advisable.  In  dislocation  of  a  ball-and-socket  joint  con- 
siderable motion  may  become  possible  and  a  new  joint  may 
form.  If  movement  does  not  produce  pain,  a  useful  new 
joint  may  be  obtained  by  the  persistent  employment  of  active 
and  passive  movements ;  if  movement  of  the  limb  does 
produce  pain,  enough  motion  will  not  be  atternpted  by  the 
patient  to  produce  a  useful  joint.  In  the  former  case  try  to 
obtain  a  useful  new  joint,  and  in  the  latter  case  try  to  reduce 
the  old  dislocation. 

In  trying  to  reduce  an  old  dislocation,  give  ether,  make 
movement  to  break  up  adhesions,  and  persist  in  making 
these  motions  until  the  head  of  the  bone  is  felt  to  move ; 
then  try  at  once  to  reduce  by  manipulation  or  extension, 
and  counter-extension,  not  waiting  for  two  days,  as  some 
suggest.  If  the  head  of  the  bone  cannot  be  made  to  move, 
the  Dieffenbach  plan  may  be  followed,  which  is  to  cut  the 
tense  restraining  bands  with  a  tenotome.  Always  remem- 
ber that  dislocations  of  a  hinge-joint,  if  left  unreduced,  will 
never  eventuate  in  a  useful  artificial  joint.  Lord  Lister,  being 
much  impressed  with  the  danger  inevitably  linked  with  for- 
cibly dragging  old  dislocations  into  place,  prefers  to  cut 
down  and  restore  the  bone,  employing,  of  course,  the  strictest 
asepsis,  and  surgeons  in  general  have  adopted  this  view. 
In  some  old  dislocations  excision  of  the  head  of  the  bone 
is  the  proper  operation. 

Special  Traumatic  Dislocations. — Lower  Jaw. — A 
dislocation  of  the  lower  jaw,  when  there  is  no  fracture,  is 
almost  invariably  forward.  Backward  dislocation  without 
fracture  is  extremely  rare,  and  some  have  maintained  that  it 
cannot  occur.  Croker  King  reported  a  case  in  1858.  Theim 
has  observed  it  seven  times  in  five  women.  The  condyle  passes 
under  the  lower  surface  of  the  auditory  canal.^  The  common 
dislocation  is  forward,  and  this  is  the  form  meant  when  we 
simply  speak  of  dislocation  of  the  jaw.  There  are  two  forms 
of  forward  dislocation — the  unilateral,  which  is  rare,  and  the 
bilateral,  which  is  common.  Dislocations  of  the  jaw  are 
commonest  in  women  and  during  middle  life.     When  the 

1  Theim,  in  Rev.  de  Ckir.,  vol.  8,  1888. 


554   J^^SEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

mouth  is  open  contraction  of  the  external  pterygoid  may 
pull  the  condyle  over  the  articular  eminence ;  this  contrac- 
tion may  be  brought  about  by  yawning,  vomiting,  scolding, 
etc.  When  the  mouth  is  open  dislocation  of  the  lower  jaw 
may  be  caused  by  a  blow  upon  the  chin  ;  it  may  also  be 
caused  by  forcing  the  mouth  more  widely  open  by  pushing 
a  bulky  body  between  the  teeth. 

Symptoms  of  Lower-jazv  Dislocations. — In  the  bilateral 
form  the  mouth  is  open  and  fixed,  and  it  cannot  be  closed, 
though  it  can  be  opened  a  little  more.  The  condyles  are 
in  front  of  the  articular  eminences,  and  are  fixed  by  the 
action  of  the  masseters  and  internal  pterygoids,  the  coronoid 
processes  being  wedged  against  the  malar  bones.  The  lower 
jaw  is  advanced  in  front  of  the  upper  and  the  face  looks 
longer  than  natural.  The  lips  cannot  close,  the  saliva  drib- 
bles, swallowing  and  speech  are  difficult,  there  is  a  depres- 
sion in  front  of  each  ear,  the  condyles  are  recognizable  in  their 
new  abodes,  the  coronoid  processes  are  detected  by  a  finger  in 
the  mouth,  and  the  masseters  and  temporals  stand  out  in  a 
state  of  rigidity.  Pain  may  be  severe  or  be  absent.  In  tRe 
unilateral  form  the  chin  goes  toward  the  sound  side,  and  the 
mouth  is  not  so  widely  open  as  in  the  bilateral  form,  neither 
is  the  jaw  so  fixed.  The  symptoms  are  similar  to  those  of 
a  bilateral  luxation,  but  are  not  so  pronounced.  The  hollow 
in  front  of  the  ear  and  the  condyle  in  an  abnormal  situation 
are  only  detected  upon  one  side.  In  an  unreduced  disloca- 
tion the  patient  may  after  a  time  establish  some  movement 
of  the  jaw,  but  the  power  of  mastication  will  always  be  im- 
paired seriously. 

Treatment  of  Loiver-ja%v  Dislocations. — In  treating  dislo- 
cations of  the  lower  jaw  the  patient  is  placed  with  his  head 
against  the  back  of  a  chair  or  against  the  body  of  an  assist- 
ant. The  surgeon,  after  wrapping  up  his  thumbs  to  protect 
them  from  being  bitten,  stands  in  front  of  the  patient,  puts 
his  thumbs  upon  the  last  molar  teeth,  and  grasps  the  chin 
with  his  free  fingers.  He  now  presses  downward  and  back- 
ward on  the  jaw,  and  as  soon  as  the  condyle  is  loosened 
closes  the  jaw  over  the  thumbs  by  pushing  up  the  chin, 
using  his  thumbs  as  levers.  If  this  procedure  fails,  w'edges 
should  be  put  between  the  molar  teeth  and  the  chin  should 
be  pushed  up  either  by  the  hands  or  by  a  tourniquet  whose 
band  is  round  the  head  and  chin.  In  a  unilateral  disloca- 
tion the  wedge  should  only  be  used  on  the  injured  side. 
In  difficult  cases  Sir  Astley  Cooper  pushed  a  round  wooden 
ruler  between  the  molar  teeth,  used  the  upper  teeth  as  a 


DISLOCATIOX  OF  THE   CLAVICLE.  555 

fulcrum,  and  raised  the  end  of  the  ruler  as  the  handle  of 
a  lever.  The  forceps  used  by  an  anesthetizer  may  depress 
the  condyle  from  its  point  of  fixation,  whereupon  the  chin 
may  be  pushed  up  and  back.  Nelaton's  plan  was  to 
put  the  thumbs  in  the  mouth  and  push  the  coronoid  pro- 
cesses backward.  In  an  old  dislocation  always  \xy  reduc- 
tion, at  least  up  to  a  period  of  six  or  seven  months.  After 
reduction  apply  a  Barton  bandage  for  o\'er  two  weeks,  taking 
it  off  once  a  day,  and  begin  passive  motion  in  the  second 
week ;  discard  the  bandage  in  the  third  week.  Liquid  diet 
is  advisable  for  three  weeks  after  the  accident.  An  unre- 
ducible dislocation  requires  osteotomy  of  the  neck  of  the 
bone,  if  the  part  cannot  be  restored  after  incision. 

Dislocation  of  the  Clavicle. — Sternal  End. — There  are 
three  forms  of  dislocation  of  the  sternal  end  of  the  clavicle, 
namely:  (i)  forward;  (2)  backward;  and  (3)  upward. 

Forward  Dislocation  of  the  Sternal  End  of  the  Clavicle. 
— The  causes  of  forward  dislocation  of  the  clavicle  are  blows, 
falls,  or  pulls  which  drive  or  draw  the  shoulder  backward. 

Syviptoihs  and  Treatment  of  Forzcard  Dislocation  of  the 
Clavicle. — The  symptoms  manifest  in  dislocation  of  the  clavi- 
cle are — prominence  in  front  of  the  sternum;  the  acromion 
is  nearer  to  the  sternum  on  the  injured  than  on  the  sound 
side ;  the  clavicular  origin  of  the  sternocleidomastoid  is 
rigid ;  movement  is  difficult  and  painful.  To  treat  a  dislo- 
cation of  the  clavicle,  pull  the  shoulders  back  against  the 
knee  of  the  surgeon,  which  is  placed  between  the  scapulae. 
Dress  with  a  posterior  figure-of-8  bandage  (Fig.  362),  or  a 
Velpeau  bandage  (Fig.  364),  the  dressing  to  be  worn  for 
three  weeks.  After  removal  of  the  dressing  apply  a  truss, 
the  pad  of  which  is  put  over  the  head  of  the  clavicle,  and 
which  instrument  is  to  be  worn  for  a  month.  Dislocation 
of  the  clavicle  is  difficult  to  keep  reduced,  but  even  if  it 
becomes  fixed  in  deformity  the  motions  of  the  arm  will  not 
be  impaired  permanently.  It  can  be  reduced  and  fixed  by 
incision  and  wiring. 

Backward  dislocation  of  the  sternal  end  of  the  clavicle 
is  very  rare.  The  causes  are  direct  violence  and  indirect  force, 
such  as  falls  or  blows  which  drive  the  shoulder  forward  and 
inward. 

Symptoms  and  Treatment  of  Backivard  Dislocation  of  the 
Clavicle. — The  symptoms  are — pain ;  loss  of  function  in  the 
arm  ;  inclination  of  head  toward  the  injured  side  ;  stiffness  of 
the  neck  ;  the  shoulder  passes  forward  and  inward,  and  often 
falls  downward ;  a  depression  exists  over  the  sternoclavicular 


556   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

joint ;  the  head  of  the  clavicle  cannot  be  felt,  or  is  found 
back  of  the  sternum.  The  displaced  clavacle  may  press  upon 
the  trachea,  the  esophagus,  or  the  great  vessels,  inducing 
dyspnea,  dysphagia,  obliteration  of  pulse  in  the  arm  of  the 
injured  side,  or  great  venous  congestion  of  the  head  (see 
Pick).  To  treat  a  backward  dislocation,  pull  the  shoulders 
backward  and  apply  a  posterior  figure-of-8  bandage  (Fig. 
362),  which  must  be  worn  for  three  weeks.  If  pressure- 
symptoms  are  urgent,  resect  the  displaced  head. 

Up"ward  dislocation  of  a  clavicle  is  very  rare.  The 
cause  is  indirect  force  which  carries  the  shoulder  downward, 
inward,  and  backward  (Smith). 


Fig.  174. — Rhoads's  apparatus  for  treating  dislocation  upward  of  the  acromial  end  of  the 

clavicle. 

Symptoms  and  Treatment  of  Upzvard  Dislocation  of  the 
Sternal  Ejid  of  the  Clavicle. — The  chief  symptom  is  impaired 
function  of  the  arm  ;  the  shoulder  passes  downward  and 
inward,  the  clavicular  axis  is  altered,  and  the  displaced  head 
is  felt.  Dyspnea  may  or  may  not  exist.  To  treat  this  dis- 
location, put  a  pad  in  the  axilla  and  press  the  elbow  to  the 
side  in  order  to  throw  the  bone  outward,  and  try  to  push  the 
head  into  place.  Apply  a  Desault  bandage  (Fig.  367) 
and  place  a  firm  pad  over  the  sternoclavicular  joint.  The 
deformity  is  apt  to  recur,  but  a  useful  limb  will  nevertheless 
be  obtained.     It  may  be  desirable  to  wire  the  bones  in  place. 

Dislocation  of  the  acromial  end  of  the  clavicle  is  almost 
always  upward,  but  it  may  be  below  the  acromion.  The  cause 


DISLOCATION  OF   THE    CLAVICLE.  55/ 

is  violent  force,  which,  if  so  apphed  to  the  scapula  as  to  drive 
the  shoulder  forward,  may  produce  a  dislocation  upward.  A 
dislocation  downward  is  due  to  blows  upon  the  upper  surface 
of  the  outer  end  of  the  clavicle. 

Svinptoins  and  Trcatuicnt. — The  symptoms  of  dislocation 
of  the  acromial  end  of  the  clavicle  are — prominence  of  the 
clavicle  upon  the  top  of  the  acromion ;  impaired  function  of 
the  arm  (it  cannot  be  lifted  over  the  head) ;  the  shoulder  falls 
downward  and  passes  inward ;  there  is  apparent  lengthening 
of  the  arm  ;  the  head  is  bent  toward  the  injured  side,  and  the 
clavicular  origin  of  the  trapezius  is  strongly  outlined  (Pick). 
In  dislocation  downward  both  the  acromion  and  the  coracoid 
are  very  prominent,  the  clavicular  axis  is  altered,  and  there 
is  depression  over  the  sternoclavicular  joint.  A  dislocation 
upward  is  reduced  by  pulling  the  shoulder  back  and  pushing 
the  bone  into  place.  The  old  method  was  to  apply  a 
Desault  bandage,  which  was  kept  on  for  three  weeks,  and 
more  or  less  deformity  was  looked  for  as  inevitable.  Stim- 
son  dresses  with  adhesive  plaster.  The  author  has  recently 
seen  a  case  treated  by  the  apparatus  of  Thomas  Leidy 
Rhoads.  The  apparatus  completely  corrected  the  deformity, 
and  the  patient  made  a  most  satisfactory  recovery.  The  es- 
sential element  of  Rhoads's  apparatus  is  a  trunk  strap  applied 
as  is  shown  in  Fig.  174.  Dislocation  downward  is  reduced 
and  treated  in  the  same  manner  as  dislocation  upward. 

The  so-called  dislocation  of  the  lower  angle  of  the 
scapula  is  not,  as  it  was  long  thought  to  be,  a  disloca- 
tion at  all.  The  lower  angle  and  vertebral  border  deviate 
from  the  chest.  This  condition  was  thought  to  be  due  to  the 
bone  slipping  from  under  the  latissimus  dorsi  muscle,  but  it 
is  now  known  to  be  due  to  paralysis  of  the  serratus  magnus 
muscle,  the  bone  being  acted  upon  by  the  trapezius,  pector- 
alis  minor,  levator  anguH  scapulae,  and  rhomboid  muscles. 
Examination  shows  that  the  scapula  will  not  rotate  normally 
forward.  This  is  demonstrated  by  extending  the  arms  in  front 
to  a  right  angle,  the  gliding  forward  of  the  scapula  upon  the 
sound  side  being  marked  and  upon  the  diseased  side  being 
slight  or  absent. 

Treatment  of  dislocation  of  the  lower  angle  of  the  scapula 
comprises  massage,  electricity,  passive  motion,  and  deep  in- 
jections of  strychnin. 

Simiiltancovs  dislocation  of  both  ends  of  the  clavicle  is  a 
very  rare  injury.     It  is  treated  as  is  single  dislocation. 

Dislocations  of  the  Humerus  (Shoulder-joint). — These 
injuries  are  quite  frequent  because  of  the  free  mobility  of  the 


558   DISEASES  .IXD    INJURIES   OF  BONES  AND  JOINTS. 

shoulder-joint,  its  anatomical  insecurity,  and  its  exposed  situ- 
ation ;  they  rarely  occur  in  the  very  young  and  in  the  aged, 
and  are  oftenest  encountered  in  muscular  young  adults. 
Four  chief  forms  of  shoulder-joint  dislocation  exist,  namely : 
(i)  forward,  inward,  and  downward,  under  the  coracoid  pro- 
cess— subcoracoid ;  (2)  downward,  forward,  and  inward,  be- 
neath the  glenoid  cavity — subglenoid ;  (3)  backward,  in- 
ward, and  downward,  under  the  spine  of  the  scapula — 
subspinous ;  and  (4)  forward,  inward,  and  upward,  under 
the  clavicle — subclavicular. 


Fig.   175. — Subcoracoid   dislocation  of  the   liumerus   (St.  Joseph's   Hospital   case;    photo- 
graphed by  Dr.  Nassau). 

A  very  rare  form  of  shoulder-joint  dislocation  has  been 
described,  which  is  known  as  the  "  supracoracoid."  Another 
rare  form  is  the  luxatio  erecta. 

Subcoracoid  Luxation. — The  subcoracoid  variety  of  dis- 
location embraces  three-fourths  of  all  the  shoulder-joint 
luxations.  It  may  be  caused  by  direct  force  driving  the 
head  of  the  humerus  forward  and  inward,  or  by  indirect 
force,  such  as  falls  upon  the  hand  or  the  elbow.  In  this 
dislocation  the  anatomical  neck  of  the  humerus  lies  upon 
the    anterior    margin    of   the    glenoid    cavity,   just    beneath 


DISLOCATIOX  OF   THE   HUMERUS.  559 

the  coracoid  process,  and  is  above  the  tendon  of  the  sub- 
scapLilaris  muscle. 

Sitbgloioid  or  axillary  liixatioi  ma\-  be  produced  b}-  con- 
traction of  the  great  pectoral  and  latissimus  dorsi  muscles 
when  the  arm  is  at  a  right  angle  to  the  bod}',  but  it  is  usually 
due  to  falls  upon  the  hand  or  the  elbow  when  the  arm  is 
raised  and  the  head  of  the  bone  is  against  the  lower  portion 
of  the  capsule.  In  this  dislocation  the  head  of  the  bone  rests 
upon  the  border  of  the  scapula,  below  the  tendon  of  the  sub- 
scapularis,  in  front  of  the  long  head  of  the  triceps,  and  above 
the  teres  muscles.  Some  obser\'ers  hold  that  most  disloca- 
tions of  the  shoulder  are  primarily  subglenoid,  the  position 
having  been  altered  by  muscular  action. 

Subspinous  luxation  is  a  rare  injury.  Pick  met  with  this 
accident  in  a  man  who,  while  having  his  hands  in  his  pockets, 
fell  upon  the  front  of  the  point  of  the  shoulder.  The  head 
of  the  bone  reposes  beneath  the  scapular  spine,  between  the 
infraspinatus  and  teres  minor  muscles. 

Subclaviailar  luxation  is  ver}'  rare.  It  is  caused  b}'  the  same 
sort  of  violence  which  produces  subcoracoid  luxation.  The 
head  of  the  bone  rests  upon  the  thorax,  below  the  clavicle 
and  underneath  the  pectoralis   major  muscle. 

In  the  rare  form  known  as  the  "  supracoracoid  "  the  head 
of  the  humerus  rests  upon  the  coraco-acromial  ligament  or 
upon  the  acromion  process  and  the  acromion  or  the  coracoid 
is  always  fractured. 

Luxatio  crccta  is  an  unusual  form  of  subglenoid  dislocation. 
The  arm  is  upright  and  the  forearm  rests  behind  the  occiput 
or  on  the  top  of  the  head,  and  the  patient  holds  it  there  to 
avoid  pain.     Judd,  Hulke,  and  Cleland  have  related  cases. 

Symptoms  of  Dislocation  of  the  SJioulder-joint. — Dislocation 
is  diagnosticated  by  (i)  pain  of  a  sickening  character  ;  (2)  flat- 
tening of  the  shoulder,  the  head  of  the  bone  ha\-ing  ceased  to 
bulge  out  the  deltoid  muscle  ;  ( 3)  apparent  projection  of 
the  acromion  through  sinking  in  of  the  deltoid ;  (4)  hollow 
beneath  the  acromion,  over  the  empt}'  glenoid  cavit}',  and  the 
bone  missed  from  its  normal  habitat.  This  hollow  may  be 
easily  appreciated  by  the  finger,  especially  when  the  extrem- 
\Xx  is  somewhat  abducted;  (5)  rigidity  (^some  movement  is 
possible,  in  the  direction  especially  of  an  existing  deformit}-, 
but  mobility  is  strictly  limited  and  attempts  at  motion  pro- 
duce great  pain) ;  (6)  the  elbow  cannot  touch  the  side  when 
the  hand  is  placed  upon  the  sound  shoulder,  and  the  hand 
cannot  be  placed  upon  the  sound  shoulder  if  the  elbow  is  to 
the  side — Dugas's  sign  (this  is  due  to  the  rotundity  of  the 


560   DISEASES  AND   INJURIES   OF  BOXES  AND  JOINTS. 

chest.  In  a  dislocation  the  head  of  the  bone  is  ah'eady  touch- 
ing the  chest,  and  the  bone,  being  approximately  straight, 
cannot  touch  it  in  two  places  at  the  same  time.  If  the  elbow 
can  be  placed  against  the  chest  with  the  hand  on  the  sound 
shoulder,  there  cannot  be  dislocation ;  if  it  cannot  be  so 
placed,  there  must  be  dislocation) ;  (7)  finding  the  head  of 
the  bone  in  a  new  situation ;  (8)  examining  by  means  of 
the  A^-rays.  Symptoms  i  to  5  inclusive  may  be  grouped  as 
Erichsen's  list  of  signs.  The  form  of  dislocation  is  made 
out  by  a  study  of  the  direction  of  the  axis  of  the  limb,  the 
existence  and  extent  of  lengthening-  or  of  shortening,  and 
the  situation  of  the  head  of  the  bone. 

The   following  table  from  T.   Pickering   Pick's  work   on 
Fractures  and  Dislocations  makes   the   above  points  clear : 


Subcoracoid. 


Subglenoid. 


Subspinous. 


Subclavicular. 


Direction  of  the 
A.xis  of  the  Limb. 


The  elbow  is  car- 
ried backward  and 
slightly  away  from 
the  side. 

The  elbow  is  car- 
ried away  from  the 
trunk  and  slightly 
backward. 

The  elbow  is 
raised  from  the  side 
and  carried  for- 
ward. 

The  elbow  is  car- 
ried outward  and 
backward. 


Alteration  in  the 
Length  of  the  Limb. 


Very     slight 
lengthening. 


Very  consider- 
able lensthenine. 


Lengthening  in- 
termediate in  de- 
gree between  the 
subglenoid  and  the 
subcoracoid. 

Shortening. 


Presence    of     the     Head 

of  the  Bone  in  New 

Situation. 


The  head  of  the 
bone  cannot  easily  be 
felt;  if  it  can,  it  is 
found  at  the  upper  and 
inner  part  of  the  axilla. 

The  head  of  the 
bone  can  easily  be  felt 
in  the  axilla. 

The  head  of  the 
bone  can  be  felt  and  be 
grasped  beneath  the 
spine  of  the  scapula. 

The  head  of  the 
bone  can  readily  be 
seen  and  be  felt  be- 
neath the  clavicle. 


In  a  shoulder-joint  dislocation  the  head  of  the  bone  may 
press  upon  the  brachial  plexus  and  produce  pain  and  numb- 
ness, and  occasionally  a  traumatic  neuritis  or  paralysis  ;  some- 
times pressure  upon  the  axillary  vein  causes  intense  edema, 
and  pressure  upon  the  axillary  artery  diminishes  or  obliter- 
ates the  pulse.  The  axillary  vessels  may  be  torn  and  the 
muscles  may  be  lacerated  badly.  The  capsule  is  torn  and 
considerable  blood  is  usually  effused.  Swelling  is  due  first 
to  hemorrhage,  and  secondly  to  inflammation.  Partial  dis- 
locations sometimes,  though  rarely,  occur.  What  is  usually 
spoken  of  as  "partial  dislocation"  or  "subluxation"  is  a 
condition  in  which  the  head  of  the  humerus  passes  forward 


DISLOCATION  OF   THE  II CM EK US. 


561 


under  the  coracoid  because  of  rupture  of  the  long  head  of 
the  biceps  or  because  this  tendon  shps  out  of  its  groove,  the 
hgaments  being  intact. 

Diagnosis  of  SJiovldcr-joint  Dislocation. — In  fracture  of  the 
neck  of  the  scapula  there  is  prominence  of  the  acromion  and 
a  hollo^v  below  it,  a  hard  body  being  felt  in  the  axilla ;  but 
the  coracoid  process  descends  with  the  head  of  the  bone, 
which  it  does  not  do  in  dislocation.  Furthermore,  in  fract- 
ure there  is  mobility ;  in  dislocation  rigidity.  In  fracture 
crepitus  is  present ;  in  dislocation  it  is  absent.  In  fracture 
the  deformity  is  easily  reduced,  but  it  at  once  recurs  ;  in  dis- 
location the  deformity  is  with  difficult}'  reduced,  but  does 
not  recur.  In  fracture  the  elbow  can  be  made  to  touch  the 
side  when  the  hand  is  upon  the  sound  shoulder ;  in  disloca- 
tion it  cannot  be  so  manipulated.  In  fracture  of  the  anatomi- 
cal neck  of  the  humerus  deformity  is  slight ;  the  head  of  the 
humerus  is  found  in  place,  and  does  not  move  when  the  shaft 
is  rotated  ;  and  the  head  is  not  in  line  with  the  axis  of  the 
bone.  Crepitus  exists  in  fracture  if  impaction  is  absent.  In 
paralysis  of  the  deltoid  there  is  distinct  flattening,  but  the 
bone  is  felt  in  place  and  there  is  no  rigidity.  The  A'-rays 
are  a  great  aid  to  diagnosis. 

Treatment  of  Shoiilderfoint  Dislocation. — Reduction  by 
manipulation  is  usually  readily  obtained  in  recent  cases  of 
shoulder-joint  dislocation.  It  is  usually  well  to  give  ether. 
Forward  dislocations  (subcoracoid.subcla\-icular,and  axillary) 
are  reduced  by  Kocher's  method  (Fig.  176):    Put  the  arm 


Fig.  176. — Kocher's  method  of  reduction  by  manipulation  :  a,  first  movement,  outward 
rotation  ;  b,  second  movement,  elevation  of  elbow ;  c,  third  movement,  inward  rotation  and 
lowering  of  the  elbow  (Ceppi ). 


against  the  side,  flex  the  forearm  to  a  right  angle  with  the 
arm,  perform  external  rotation  of  the  arm  until  resistance  be- 
comes decided,  raise  the  elbow,  make  internal  rotation,  bring 
the  arm  across  the  front  of  the  chest  and  lower  the  elbow. 
The  formula  is,  flexion  of  the  forearm,  external  rotation,  lift- 

36 


562    DISEASES  AND   INJURIES   OE  BONES  AND  JOINTS. 

ing  elbow  forward,  internal  rotation  of  the  arm,  and  lowering 
the  elbow.  If  in  trying  Kocher's  plan  external  rotation  of  the 
humerus  does  not  take  place,  abandon  the  method,  as  per- 
sistence will  fracture  the  humerus.  Another  method  of  ma- 
nipulation is  as  follows :  if  the  right  shoulder  is  dislocated, 
the  surgeon  stands  behind  the  patient  (who  is  sitting  erect) ; 
if  the  left  shoulder  is  dislocated,  he  stands  in  front  of  the 
patient.  The  surgeon  holds  the  forearm  flexed  upon  the 
arm  with  his  right  hand  and  makes  external  traction  and 
rotation,  and  with  the  fingers  of  his  left  hand  he  tries  to  force 
the  bone  into  place. 

In  Henry  H.  Smith's  method  for  forward  dislocations  the 
surgeon  stands  in  front  of  the  patient.  If  the  left  shoulder 
is  dislocated,  the  surgeon  grasps  it  with  his  left  hand;  if  the 
riglit  shoulder  is  dislocated,  he  grasps  it  with  his  right  hand, 
the  thumb  resting  on  the  head  of  the  bone.  With  his  disen- 
gaged hand  the  surgeon  grasps  the  elbow,  abducts  it,  makes 
traction  and  external  rotation,  and  suddenly  sweeps  the  elbow 
inward,  aiming  it  at  the  sternum,  and  tries  with  his  thumb  to 
push  the  bone  into  place.  In  subspinous  luxations  reduction 
may  be  effected  if  the  surgeon  stands  behind  the  patient, 
makes  abduction,  traction,  and  internal  rotation,  sweeps  the 
elbow  inward  toward  the  spine,  and  with  the  thumb  aids  the 
bone  in  its  return  into  position.  Raising  the  elbow  far  above 
the  head  and  sweeping  it  inward  will  reduce  some  disloca- 
tions. As  the  head  of  the  bone  slips  back  a  distinct  jar  is 
felt  and  a  snap  is  heard,  the  motions  of  the  joint  are  again 
obtainable,  and  with  the  hand  on  the  opposite  shoulder  the 
elbow  may  be  made  to  touch  the  side. 

Reduction  by  Extension. — In  reduction  of  shoulder-joint 
dislocation  by  extension  the  patient  is  anesthetized  and 
placed  upon  a  low  bed  or  upon  the  floor.  The  •  surgeon 
then  places  his  foot,  covered  only  by  a  stocking,  in  the  axilla. 
Place  the  sole  of  the  foot,  not  the  heel,  against  the  chest  high 
up,  the  instep  being  made  to  touch  the  humerus  and  the  heel 
the  border  of  the  shoulder-blade,  a  towel  being  first  put  into 
the  axilla  to  rest  the  foot  against  (Fig.  177).  If  the  left  arm 
is  dislocated,  use  the  left  foot,  and  vice  versa.  The  elder 
Gross  approved  of  making  extension  while  sitting  between 
the  patient's  limbs.  Make  steady  extension,  which  will  in 
many  cases  bring  about  the  reduction.  If  it  fails  to  cause 
reduction,  bring  the  patient's  arm  across  the  chest  and  use 
the  foot  as  the  fulcrum  of  a  lever.  If  the  humerus  is  pretty 
firmly  fixed  in  its  abnormal  position,  make  counter-extension 
with  a  foot  in  the  axilla  and  make  extension  by  fixing  a  clove- 


DISLOCATION  OF  THE   HUMERUS. 


563 


hitch  (Fig.  178)  above  the  elbozc  2i.\\d  fastening  to  it  bands  which 
go  over  one  shoulder  and  under  the  other  shoulder  of  the 
surgeon.  The  back  may  be  used  for  extension,  the  hands 
being  left  free  for  manipulation  (AUis's    and   Pick's   plan). 


Fig.  177. — Reduction  of  shoulder-joint  disloca- 
tion by  the  foot  in  the  axilla  (Cooper). 


Fig.  178. — Clove-hitch  knot  applied 
above  the  wrist.  In  dislocation' of  the 
shoulder  this  knot  is  put  above  the  elbow 

(after  Erichsen). 


Lateral  extension  is  used  b}-  some  surgeons.  The  patient 
hes  down,  a  large  piece  of  canvas  is  split,  the  arm  is  passed 
through  the  split  and  the  body  is  thus  fixed.  The  arm  is 
pulled  to  a  right  angle  with  the  body  and  traction  is  applied. 
The  late  Prof  Joseph  Pancoast  favored  Sir  Astley  Cooper's 
method  of  placing  the  unanesthetized  patient  in  a  chair  and 
using  the  knee  as  a  fulcrum,  pushing 
the  elbow  to  the  side  (Fig.  179). 
Brunus,  in  the  thirteenth  centurv^ 
devised  the  method  of  upzvard  ex- 
tension.     In    applying    this    method 


Fig.  179. — Reduction  of  shoul- 
der-joint dislocation  by  the  knee 
in  the  axilla  (Cooper). 


Fig.  180. — Reduction  of  shoulder-joint  disloca- 
tion by  upward  e.xtension  (Cooper). 


the  surgeon  takes  his  place  behind  the  patient,  steadies  the 
scapula  with  his  hand,  and  carries  the  patient's  arm  upward 
and  backward  above  his  head,  making  extension  and  external 
rotation  (Fig.  180).  La  Mothe's  method  is  applied  with  the 
patient  supine  upon  the  floor.     The  surgeon  places  his  foot 


564   DISEASES  AND    INJURIES    OE  BONES  AND  JOINTS. 

upon  the  shoulder  to  make  counter-extension,  and  makes 
extension  as  in  Brunus's  method.  It  is  a  useful  expedient, 
when  either  of  these  plans  is  applied,  to  have  an  assistant 
make  the  traction  while  the  surgeon  manipulates  the  head 
of  the  bone.  Cock  advises,  when  reduction  fails,  that  an 
air-pad  be  placed  in  the  axilla  and  the  arm  be  bound  to  the 
side — a  method  by  which  reduction  will  often  take  place  after 
two  or  three  days.  The  pulleys  should  not  be  used,  as  they 
develop  a  dangerous  force,  antiseptic  incision  being  a  safer 
and  a  better  expedient.  After  incision  try  to  restore  the  bone 
to  place.  In  an  old  dislocation  it  may  be  necessary  to  resect 
the  head  of  the  bone. 

In  reducing  a  dislocation  the  axillary  artery  or  vein  may 
be  ruptured,  fracture  of  the  neck  of  the  humerus  may  take 
place,  injury  to  the  brachial  artery  may  occur,  or  the  soft 
parts  may  be  badly  damaged.  After  reducing  a  dislocation 
apply  a  Velpeau  bandage,  keep  the  shoulder  immobile  for 
one  week,  then  make  passive  motion  daily,  reapplying  the 
dressing  after  each  seance.  The  patient  may  wear  a  sling 
alone  during  the  third  week,  after  which  period  he  may  use 
the  arm.  (For  old  dislocations  and  compound  dislocations 
see  pages  552,  553).  Reduction  of  old  dislocations  may 
sometimes  be  effected  by  manipulation.  Extension  may 
have  to  be  used,  and  ether  may  be  required.  In  old  dislo- 
cations try  to  reduce,  after  breaking  up  adhesions,  by  forced 
flexion  and  strong  extension.  After  reduction  immobilize 
for  three  weeks,  and  begin  passive  motion  after  seven  da\'s. 

If  a  dislocation  is  complicated  by  a  fracture  of  the  humerus, 
try  to  pull  the  head  of  the  bone  opposite  the  joint.  This 
may  be  possible  if  the  two  fragments  are  held  partly  together 
by  a  fair  amount  of  periosteum  and  muscle.  Traction  is  made 
upon  the  arm,  and  an  attempt  is  made  to  manipulate  the  head 
into  the  socket  (Allis's  plan  in  the  hip).  McBurney  incises, 
fixes  a  hook  in  the  scapula  and  a  hook  in  the  head  of  the 
hum'erus,  pulls  the  head  into  place,  and  wires  the  fragments 
(Figs.  Ill,  112,  113).  In  an  emergency  gimlets  may  be 
used  instead  of  the  hooks.  In  some  cases  it  is  necessary  to 
excise  the  head  of  the  bone. 

Dislocations  of  the  Elbow-joint. — Injuries  of  the  elbow- 
joint  are  not  rare,  and  they  are  commonest  in  children. 
Both  bones  or  only  one  ,bone  may  be  dislocated,  and  the 
dislocation  may  be  partial  or  complete. 

Dislocation  of  Both  Bones  Backward. — The  causes  of 
backward  dislocation  of  both  bones  of  the  forearm  are 
falls  upon  the  extended  hand  or  twists  inward  of  the  ulna 


DISLOCATION'   OF   HIE   FOREARM. 


565 


(Malgaigne).     The  coronoid  process  lodges  in  the  olecranon 
fossa  of  the  humerus. 

Symptoms  of  Backward  Dislocation. — In  complete  disloca- 
tion of  both  bones  of  the  forearm  the  olecranon  is  very- 
prominent  ;  the  distance  between  the  point  of  the  olecranon 
and  the  apex  of  the  inner  condyle  is  notably  greater  than  on 
the  sound  side ;  the  forearm  is  flexed,  supinated,  and  short- 
ened ;  the  lower  end  of  the  humerus  projects  in  front  of  the 
joint,  below  the  skin-crease ;  the  head  of  the  radius  is  found 
back  of  the  outer  condyle ;  and  there  are  the  general  symp- 
toms of  dislocation.  Fracture  of  the  coronoid  rarely  occurs 
with  backward  dislocation,  but  if  it  does  occur  there  will 
be  crepitus  and  mobility.  Fracture  at  the  base  of  the  con- 
dyles is  distinguished  from  dislocation  of  both  bones  of  the 
forearm  backward  by  the  following  points  :  in  fracture  there 
are  found  the  ordinary  symptoms ;  measurement  from  the 
condyles  to  the  styloid  processes  does  not  show  shortening ; 
there  is  no  alteration  of  the  normal  relation  between  the  olec- 
ranon process  and  the  condyles ;  and  the  projection  in  front 
of  the  joint  is  above  the  crease  of  the  bend  of  the  elbow. 

Treatment  of  Backivard  Dislocation. — Reduction  must  be 
effected  early  in  dislocation  of  both  bones  of  the  forearm, 
or  it  will  be  found  impos- 
sible, and  an  unreduced 
dislocation  means  a  limb 
without  the  powers  of 
flexion,  pronation,  and 
supination.  The  surgeon 
places  his  knee  in  front 
of  the  elbow-joint,  grasps 
the  patient's  wrist,  presses 
upon  the  radius  and  ulna 
with  his  knee,  and  bends 
the  forearm  with  consid- 
erable force,  the  muscles 
pulling  the  bones  into  place  (Sir  Astley  Cooper's  plan). 
Forced  flexion,  traction,  and  extension  may  be  tried  (Fig. 
181).  Put  the  arm  in  Jones's  position  for  two  weeks,  and 
make  passive  motion  daily  after  the  first  few  days. 

Dislocation  of  Both  Bones  Forward. — The  cause  of  for- 
ward dislocation  of  both  bones  of  the  forearm  is  a  blow 
on  the  olecranon  when  the  arm  is  flexed.  It  is  a  rare 
accident. 

Symptoms  and  Treatment. — The  symptoms  of  forward 
dislocation  of    both    bones  of    the    forearm    are — forearm 


Reduction  of  elbow-joint  dislocation. 


566   DISEASES  AXn   INJL'RIES   OF  BONES  AND  JOENTS. 

is  flexed  and  lengthened ;  some  slight  motion  is  possible  ; 
olecranon  is  on  a  level  with  the  condyles  if  unfractured, 
hence  its  prominence  is  gone ;  the  humeral  condyles  are 
felt  posteriorly,  and  the  radius  and  ulna  are  felt  anteriorly. 
The  trcatinoit  of  this  injury  consists  in  early  reduction,  which 
is  accomplished  by  means  of  forced  flexion  and  pressure, 
placing  the  part  in  Jones's  position  for  two  weeks,  and 
making  passive  motion  daily  after  the  first  few  days. 

Lateral  dislocations  of  both  bones  of  the  forearm  are 
usually  incomplete.' 

Symptoms  and  Treatment  of  Ontivard  Dislocation. — The 
symptoms  of  outward  dislocation  of  both  bones  of  the 
forearm  are — forearm  is  flexed,  fixed,  and  pronated ;  joint 
is  widened ;  the  head  of  the  radius  projects  externally 
and  has  a  depression  above  it;  the  inner  condyle  projects 
internally  and  has  a  depression  below  it ;  the  olecranon  is 
nearer  than  normal  to  the  external  condyle  and  further 
than  normal  from  the  internal  condyle.  Reduction  is  ef- 
fected by  extension  of  the  forearm  and  pressure  inward  upon 
the  head  of  the  radius.  Apply  an  ascending  spiral  reverse 
bandage  of  the  forearm,  a  figure-of-8  bandage  of  the  elbow- 
joint,  and  a  sling.  Make  passive  motion  after  a  few  days. 
The  bandages  must  be  worn  for  two  weeks. 

Symptoms  and  Treatment  of  Inward  Dislocation. — In  dis- 
location inward  of  both  bones  of  the  forearm  the  posi- 
tion of  the  forearm  is  the  same  as  that  in  dislocation  out- 
ward; the  sigmoid  cavity  of  the  ulna  projects  internall}%  and 
the  external  condyle  projects  externally.  Reduction  is 
effected  by  extension  of  the  forearm  and  pressure  outward 
on  the  ulna,  subsequent  treatment  being  the  same  as  that 
employed  in  the  preceding  form. 

Dislocation  of  the  ulna  alone  is  very  rare,  and  can  only 
take  place  backward. 

Symptoms  and  Treatment. — Dislocation  of  the  ulna  alone 
is  indicated  by  the  forearm  being  flexed  and  pronated.  The 
head  of  the  radius  is  found  in  place,  and  the  olecranon  pro- 
jects posteriorly.  The  treatment  of  this  injury  is  the  same 
as  that  for  dislocation  of  both  bones. 

Dislocation  of  the  Radius  Forward. — Dislocation  of  the 
radius  forward  is  the  commonest  form  of  dislocation  of  the 
elbow.  This  injury  is  caused  by  a  fall  upon  the  hand  with 
the  forearm  in  pronation  and  extension,  or  is  produced  by 
blows  on  the  back  of  the  joint ;  forced  pronation  alone  will 
not  cause  it. 

Symptoms  and  Treatment. — The  symptoms  in  dislocation 


DISLOCATIOX  OF   THE   RADIUS.  567 

of  the  radius  forward  are — forearm  midway  between  prona- 
tion and  supination,  and  semiflexed ;  attempts  to  increase 
flexion  cause  the  radius  to  strike  against  the  humerus  with 
a  distinct  blow ;  the  head  of  the  radius  is  felt  in  front  of 
the  outer  condyle  and  is  missed  from  its  proper  abode.  Re- 
duction is  eftected  by  flexion  over  the  knee,  extension,  and 
manipulation.  Subsequent  treatment  is  Jones's  position  and 
passi\"e  motion.  Deformity  is  apt  to  recur  after  reduction, 
because  of  rupture  of  the  orbicular  ligament. 

Dislocation  of  the  radius  back-ward  is  caused  by  falls 
on  the  hand  or  by  blows  on  the  front  of  the  joint. 

Symptoms  and  Treatment. — Backward  dislocation  of  the 
radius  is  indicated  by  the  forearm  being  slightly  flexed 
and  fixed  in  pronation,  by  some  impairment  of  flexion  and 
extension,  and  by  the  radius  being  felt  behind  the  outer 
condyle.  Reduction  is  effected  by  flexion  over  the  knee, 
extension,  and  manipulation,  and  the  subsequent  treatment 
is  the  same  as  that  given  for  the  preceding  dislocation. 

Dislocation  of  the  radius  out^ward  is  ver}^  rare.  In 
this  injury  the  head  of  the  radius  is  distinctly  felt.  Reduc- 
tion is  eftected  by  extension  and  pressure ;  the  subsequent 
treatment  is  the  same  as  that  for  the  above-mentioned  dis- 
locations. 

Subluxation  of  the  Head  of  the  Radius. — This  name  is 
given  to  an  injur}"  which  is  very  frequent  in  children  between 
two  and  four  years  of  age.  It  results  from  traction  upon  the 
hand  or  the  forearm,  and  often  arises  when  the  nurse  or  the 
mother  pulls  upon  a  child's  arm  to  save  it  from  a  fall  or  to 
lift  it  over  a  gutter.  Some  writers  hold  that  pronation  is 
required,  as  well  as  extension,  to  produce  the  injury ;  many 
surgeons  claim  that  extension  and  adduction  are  the  causa- 
tive forces.  Hutchinson  maintains  that  supination  may  cause 
subluxation.     Bardenheuer  assigned  falls  as  causes. 

The  symptoms  are  ver\"  characteristic.  The  histor}'  points 
to  the  injur}'.  Pain,  and  often  a  click,  may  be  felt  in  the 
wrist  at  the  time  of  the  accident.  The  arm  hangs  by  the 
side,  with  the  elbow-joint  slightly  flexed  and  the  forearm 
midway  between  pronation  and  supination.  Flexion  to  a 
less  angle  than  60°  and  complete  extension  are  resisted  and 
are  very  painful,  but  movements  between  60°  and  130°  are 
free  and  painless.^  The  movements  of  the  wrist-joint  are 
free  and  painless.  The  elbow-joint  presents  no  deformity. 
Pressure  over  the  head  of  the  radius  causes  pain.     Strong 

'  See  the  instructive  article  by  W.  W.  Van  Arsdale,  in  the  Annals  of  Surgery, 
vol.  ix.,  1S89. 


568    DISEASES  AND   IXJURIES   OE  BONES  AND  JOEKTS. 


pronation  is  painful ;  strong  supination  is  very  painful,  and 
there  seems  to  be  a  mechanical  obstacle  to  its  performance. 
Forced  supination  develops  a  distinct  click  at  the  head  of 
the  radius,  and  causes  pronation  and  supination  to  become 
natural  and  free  from  pain.  The  condition  will  be  repro- 
duced if  a  splint  is  not  used.  The  nature  of  the  lesion  is  not 
understood,  and  various  conditions  have  been  thought  to 
exist  by  different  observers.  Among  them  may  be  men- 
tioned the  following :  a  slight  anterior  displacement  of  the 
head  of  the  radius  ;  a  slight  posterior  displacement ;  locking 
of  the  tuberosity  of  the  radius  behind  the  inner  edge  of  the 
ulna ;  dislocation  of  the  triangular  cartilage  of  the  wrist ; 
intracapsular  fracture  of  the  radial  head ;  painful  paralysis 
from  nerve-injury;  displacement  by  elongation,  the  return 
of  the  bone  being  prevented  by  collapse  of  the  capsule ;  and 
the  slipping  up  of  the  margin  of  the  orbicular  ligament  over 
the  rim  of  the  head  of  the  radius. 

Tiratvient. — Place  the  forearm  at  a  right  angle  to  the  arm 
and  make  forcible  supination ;  apply  an  anterior  angular 
splint,  and  have  it  worn  for  four  or  five  days,  or  put  the 
part  in  Jones's  position  for  an  equal  period. 

Dislocations  of  the  wrist,  which  are  very  rare,  are 
caused  by  falls  upon  the  hand. 

Backward  Dislocation  of  the  Wrist. — Synnptovis. — The 
deformity  in  backward  dislocation  of  the  wrist  (Fig.  182,  k) 
resembles  that  of  Colles's  fracture  (Fig.  182,  b).  The  fingers 
are  flexed,  the  wrist  is  bent  backward,  the  radius  projects 


Fig.  182. — Deformity  in  dislocation  of  the  wrist  backward  (a)  and  in  Colles's  fracture  (b) 

(Stimson). 

on  the  front  of  the  wrist,  the  carpus  projects  on  the  dorsal 
surface  of  the  forearm,  the  relation  of  the  styloid  process  of 
the  radius  to  the  styloid  process  of  the  ulna  is  unaltered  (it  is 
altered  in  Colles's  fracture),  there  is  rigidity,  and  crepitus  is 
absent  (Fig.  182). 

Forward  dislocation  of  the  wrist,  which  is  very  unusual, 
is  caused  by  a  fall  upon  the  back  of  the  hand. 

Syinptoins  and  Trcatmoit. — In  forward  dislocation  of  the 
wrist  the  radius  and  ulna  project  posteriorly  and  the  carpus 


DISLOCATIOA'   OF   THE    'JIIUMB.  569 

projects  in  front.  The  tixatiiicnt  in  both  of  these  dislocations 
is  reduction  by  extension  and  manipulation,  the  use  of  a  Bond 
splint  for  ten  days,  and  the  employment  of  passive  motion 
after  five  or  six  days. 

Dislocation  at  the  inferior  radio-ulnar  articulation, 
which  is  also  very  rare,  is  caused  by  twists. 

Symptoms  and  Treatment. — In  forward  dislocation  at  the 
inferior  radio-ulnar  articulation  the  forearm  is  pronated,  the 
space  between  the  styloid  processes  is  diminished,  and  the 
ulna  forms  a  projection  posteriorly.  In  backzvard  disloca- 
tion the  forearm  is  supinated,  the  space  between  the  styloid 
processes  is  diminished,  and  the  ulna  projects  in  front.  Re- 
duction is  accomplished  by  extension  and  manipulation.  Two 
straight  splints  (as  in  fracture  of  both  bones)  are  to  be  ap- 
plied for  four  weeks,  and  passive  motion  is  to  be  made  in 
the  third  week. 

Dislocation  of  Individual  Carpal  Bones. — Pick  says 
there  is  one  weak  spot,  which  is  "  between  the  head  of  the 
OS  magnum  and  the  scaphoid  and  semilunar  bones,"  and  the 
OS  magnum  may  be  forced  up.  The  os  magnum  is  the  only 
bone  dislocated  with  any  frequency,  and  the  injury  is  caused 
by  forced  flexion  of  the  wrist. 

Symptoms  and  Treatment. — The  symptom  of  dislocation 
of  the  carpal  bones  is  a  firm  projection  which  becomes  more 
prominent  during  flexion  of  the  wrist.  The  treatment  is  ex- 
tension and  manipulation,  a  Bond  splint  being  Avorn  for  three 
weeks. 

Dislocations  of  metacarpal  bones  are  rare.  The  first 
metacarpal  bone  is  most  liable  to  dislocation. 

Symptoms  and  Treatment. — Dislocations  of  the  metacarpal 
bones  are  obvious  because  of  projection.  The  dislocations 
are  reduced  by  extension  and  manipulation,  a  straight  splint 
and  large  pad  for  the  palm  are  applied  (as  in  fracture  of  the 
metacarpus),  and  the  splint  is  to  be  worn  for  three  weeks. 

Dislocations  at  the  metacarpophalang-eal  articulations 
are  rare,  and  backward  dislocation  is  the  most  common. 
The  cause  is  a  fall  upon  the  hand. 

Symptoms  and  Treatment. — Dislocated  metacarpophalan- 
geal articulations  are  obvious.  Reduction  is  easily  effected 
by  extension  and  manipulation,  except  in  the  case  of  the 
thumb.     A  splint  must  be  worn  for  three  weeks. 

Dislocation  of  the  Metacarpophalang-eal  Joint  of  the 
Thumb. — In  this  dislocation  the  phalanx  usually  passes 
backward. 

Symptoms. — Symptoms  of  baekivard  dislocation  are — the 


5/0   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

base  of  the  first  phalanx  rests  upon  the  metacarpal  bone ; 
the  head  of  the  metacarpal  bone  projects  forward  and  button- 
holes the  muscles  of  the  thumb ;  the  first  phalanx  of  the 
thumb  is  strongly  extended,  and  the  terminal  phalanx  is 
semiflexed.  The  symptoms  oi  foi'zvard  dislocation  are — the 
base  of  the  first  phalanx  is  felt  in  the  palm,  and  the  head  of 
the  metacarpal  bone  is  felt  posteriorly. 

Treatinc)it.-;-\n  treating  backward  dislocation  of  the  meta- 
carpophalangeal joint  of  the  thumb,  reduction  is  difficult: 
because  of  the  head  of  the  bone  being  caught  in  the  perfora- 
tion of  the  flexor  muscle.  Always  give  ether.  Keetley'.s 
directions  are  to  adduct  the  metacarpal  bone  into  the  palm 
(to  relax  the  muscles)  and  to  have  an  assistant  hold  it ; 
bend  the  thumb  strongly  back,  extend,  pull  the  thumb 
toward  the  fingers,  and  suddenly  flex.  To  get  a  firm 
enough  grasp  for  these  manipulations  use  the  apparatus 
of  Charriere  or  of  Levis  (Figs.  183,  184).  If  the  above 
maneuvers    fail,    perform    tenotomy    or    incise    freely    and 


Levis's  splint  applied. 


reduce.  After  reduction  of  this  dislocation  a  splint  must 
be  worn  for  three  weeks.  In  forward  dislocation  reduction 
is  easily  effected  by  strong  extension  and  forced  flexion.  A 
splint  is  to  be  worn  for  three  weeks. 

Dislocations  of  the  phalanges  may  be  complete  or  may  be 
partial.  They  are  commonest  between  the  first  and  second 
phalanges. 

Symptoms  and  Treatment. — Dislocations  of  the  phalanges 
are  obvious.  In  treating  such  dislocations  employ  extension 
and  manipulation,  and  use  a  splint  for  one  week. 


DISLOCATIOX   OF   THE   FEMUR.  5/1 

Dislocations  of  the  Ribs  and  Costal  Cartilages. — The 
ribs  may  be  dislocated  from  the  vertebrae.  This  accident  is 
rarely  uncomplicated,  and  cannot  be  differentiated  from  fract- 
ure. The  diagnosis  is  rarely  made,  and  the  injury  is  treated 
as  a  fracture.  The  ribs  may  be  dislocated  from  their  carti- 
lages, one  or  more  ribs  being  displaced.  The  end  of  the  rib 
forms  an  anterior  projection,  there  is  a  depression  over  the 
cartilage,  and  crepitus  is  absent.  Treatment  is  the  same  as 
that  employed  for  fractured  ribs.  The  costal  cartilages  may 
be  displaced  from  the  sternum,  forming  an  anterior  projec- 
tion upon  this  bone.  Reduction  is  brought  about  by  placmg 
the  patient  upon  a  table,  with  a  sand  pillow  between  the 
scapulse,  pushing  back  the  shoulders  and  chest,  and  forcing 
the  cartilage  into  place.  The  dressings  are  the  same  as  those 
used  in  fractured  sternum.  The  cartilages  of  the  lower  ribs 
(sixth,  seventh,  eighth,  ninth,  and  tenth)  may  be  separated. 
The  inferior  cartilage  goes  forward  and  can  be  felt.  Pick 
states  that  reduction  is  brought  about  by  causing  the  patient 
to  hold  the  chest  full  of  air  while  efforts  are  made  to  push 
the  cartilage  into  place.     Dress  as  for  fractured  ribs. 

Dislocations  of  the  Sternum.— In  dislocations  of  the 
sternum  the  manubrium  may  be  separated  from  the  gladio- 
lus in  young  subjects.  The  syviptovis  and  treatment  are  the 
same  as  those  in  fracture  (page  439). 

Pelvic  dislocations  are  almost  always  complicated  with 
fracture.  A  pubic  bone  can  be  dislocated  by  falls  from  a 
height  or  by  applying  violent  force  to  the  acetabula.  The 
dislocation  mav  be  up  or  down,  front  or  back,  and  it  may 
damage  the  urethra  or  the  bladder.  The  patient  cannot 
standi  there  are  great  pain  and  recognizable  deformit>^  Treat 
by  moulding  the  bones  into  place,  by  applying  a  pelvic  belt, 
and  by  rest  in  bed  for  four  weeks.  Dislocations  of  the 
sacro-iliac  joint  are  produced  by  falls.  Movement  on  the 
part  of  the  patient  is  difficult  or  impossible ;  there  is  violent 
pain,  and  often  paralysis  (from  pressure  upon  nerves).  In 
dislocation  backward  there  is  an  apparent  shortening  of  the 
leg,  eversion  of  the  foot  exists,  and  the  ilium  moves  poste- 
riorly and  upward.  In  dislocation  forward  the  anterior  supe- 
rior iliac  spine  projects  and  the  pelvis  is  broadened.  Sacro- 
iliac dislocations  are  reduced  by  holding  the  pelvis  firm  and 
making  extension  with  a  pulley.  The  patient  stays  in  bed 
for  four  weeks  and  wears  a  pelvic  belt  as  in  fracture. 

Dislocations  of  the  Femur  (Hip-joint).— These  injuries 
are  rare,  as  the  hip-joint  is  very  strong.  They  occur  m 
young  adults.     In  forcible  extension  the  head  of  the  femur 


572    DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS. 

presses  against  the  capsule,  but  the  capsule  here  is  very 
thick,  and  certain  muscles,  the  rectus,  psoas,  and  iliacus,  are 
pulled  tight  and  serve  to  strengthen  the  capsule.  The  head 
of  the  bone  cannot  go  directly  upward,  because  of  the  ace- 
tabulum (Edmund  Owen).  The  weak  point  of  the  acetabular 
rim  is  below ;  the  weak  part  of  the  capsule  is  also  below ; 
hence  forced  abduction  is  apt  to  take  the  head  of  the  bone 
through  the  lower  part  of  the  capsule,  a  dislocation  occur- 
ring primarily  into  the  thyroid  foramen.  The  signs  of  the 
dislocation  depend  upon  the  untorn  portion  of  the  capsule. 
The  Y-ligament  and  more  than  the  Y-ligament  usually 
escapes  laceration.  Vessels  are  rarely  injured.  Muscles  are 
often  torn.  In  some  cases  the  sciatic  nerve  is  lacerated, 
bruised,  or  caught  up  on  the  neck  of  the  bone.  Four  forms 
of  hip-joint  dislocation  exist:  (i)  upward  and  backward,  on 
the  dorsum  of  the  ilium ;  (2)  backward,  into  the  sciatic 
notch ;  (3)  downward,  into  the  obturator  foramen ;  and  (4) 
inward,  on  the  pubes. 

All  dislocations  are  primarily  inward  or  outward.  From 
these  initial  positions  the  head  may  be  shifted  to  any  region 
about  the  socket  within  reach  of  the  remnant  of  untorn  cap- 
sule (Oscar  H.  Allis).  AUis  would  reject  the  old  classi- 
fication.    He  would  suggest  the  following  : 

Loj  thyroid,      I      ^jj  p^^^^j^^  abduction  and 
(  out\vard  rotation. 


All  present   adduction   and 
inward  rotation. 


Mid- 
High 
Reversed  thyroid : 
Low  dorsal. 
Mid- 
High       " 

Dislocation  upon  the  dorsum  of  the  ilium  comprises  one- 
half  of  all  hip-dislocations.  It  is  caused  by  a  fall  or  a  blow 
when  the  limb  is  flexed  and  abducted  (as  in  carrying  a 
weight  upon  the  shoulder),  by  a  fall  upon  the  knees  or  feet, 
by  a  weight  striking  the  back  while  bending,  etc.  Allis  says 
rotation  inward  is  the  chief  element  in  its  production.  In 
this  dislocation  the  head  of  the  femur  goes  upward  and 
backward,  rests  upon  the  ilium,  and  is  always  above  the 
tendon  of  the  obturator  internus  muscle.  This  dislocation 
is  secondary  to  a  thyroid  dislocation,  because  of  muscular 
action  shifting  the  bone  from  its  initial  seat  of  displacement. 

Signs. — Dislocation  on  to  the  dorsum  of  the  ilium  is  indi- 
cated by  the  following  symptoms  :  the  buttock  looks  flat  and 
broad ;  the  srreat  trochanter  is  above  Nelaton's  line  and  is 


DISLOCATIOX  OF   THE  FEMUR. 


:>/  0 


deeply  placed  ;  the  head  of  the  bone  can  be  detected  in  its  new 

situation  ;  deep  pressure  in  front  of  the  joints  finds  a  hollow ; 

the  leg  is  shortened  by  about  two  or  three  inches,  as  a  rule ; 

the  fascia  lata  is  relaxed ;  in  some  thin  people 

the  socket  can  be  outlined ;  when  the  patient  is 

recumbent  the  injured  extremity  can  be  brought 

to  the  perpendicular  without   flexing  the   leg 

( Allis) ;  the  knee  is  slightly  flexed  ;  the  thigh  is 

slightly  flexed,  inwardly  rotated,  and  adducted 

(Fig.  185),  this  is  shown  by  the  fact  that  the  axis 

of  the  thigh  of  the  injured   side,  if  prolonged, 

would  pass  through  the  lower  third  of  the  sound 

thigh) ;  when  the  capsule  is  extensiveh'  lacerated 

there  may  be  no  adduction  and  may  be  eversion 

(Allis) ;  the  heel  is  raised,  and  the  great  toe  of 

the  foot  of  the  injured  side  rests  upon  the  front 

of  the  instep  or  the  ankle  of  the  sound  side  ;     .  F'g-  185.— hip- 

■     •  1-,  •     .  1         .  ,    •      •  .  joint  dislocation  : 

rigidit}' exists  ;  voluntary  movement  is  impossi-  upward,  or  on  the 
ble,  though  some  passive  motion  is  possible  in  fnumTcooperl^^ 
the  direction  of  the  deformit}^  (the  deformit}- 
can  be  made  more  marked).  If  a  patient  is  recumbent  and 
the  knees  vertical,  the  foot  of  the  sound  extremit}^  is  free  of 
the  bed,  but  the  foot  of  the  injured  extremity  touches  the 
bed  (i\llis's  sign). 

Diag-nosis. — Examine  first  without  anesthesia,  and  then 
again  while  the  patient  is  anesthetized.  The  A'-rays  are 
valuable  in  diagnosis.  Dislocation  is  separated  from  intra- 
capsular fracture  b}'  noting  the  inversion,  the  great  shorten- 
ing, the  absence  of  crepitus,  the  age  of  the  subject,  and  the 
nature  of  the  force.  The  nature  of  the  force,  the  inversion, 
and  the  absence  of  crepitus  mark  the  diagnosis  from  extra- 
capsular fracture. 

Trcatuicnt. — The  chief  obstacle  to  reduction  in  dislocation 
on  to  the  dorsum  of  the  ilium,  Bigelow  states,  is  the  untom 
portion  of  the  capsule,  especially  the  Y-ligament.  The  ilio- 
femoral, Y,  or  Bigelow's  ligament  resembles  an  inverted  Y, 
arises  from  the  anterior  inferior  spine  of  the  ilium,  is  inserted 
into  the  anterior  intertrochanteric  hne,  and  is  incorporated 
into  the  front  of  the  capsule.  To  reduce  a  dislocation  this 
ligament  must  be  relaxed  by  manipulation  or  be  torn  by 
extension.  Manipulation  makes  the  head  of  the  bone  re- 
trace its  steps  over  the  same  route  it  took  in  emerging.  Give 
ether  ;  place  the  patient  supine  upon  a  mattress  on  the  floor  ; 
flex  the  leg  on  the  thigh  (to  relax  the  hamstrings),  the  thigh 
on  the  pelvis;  increase  the  adduction  over  the  middle  line; 


574   DISEASES  AND   INJURIES   OE  BONES  AND  JOINTS. 


strongly  abduct ;  perform  external  rotation  and  extension. 
This  treatment  may  be  summed  up  as  flexion,  adduction, 
external  circumduction,  and  extension  ;  or,  as  Pick  puts  it, 
"  bend  up,  roll  out,  turn  out,  and  extend."  Allis's  advice  is  to 
fix  the  pelvis  to  the  floor,  lift  the  head  of  the  bone  to  the  level 
of  the  socket,  rotate  outward  by  carrying  the  leg  toward 
the  pubis,  and  extend  the  femur.  If  extension  and  counter- 
extension  are  employed,  make  extension  in  the  axis  of  the 
dislocated  limb  and  obtain  counter-extension  by  a  perineal 
band.  The  extension  band  is  fastened  to  the  thigh  by  a 
clove-hitch.  After  reduction  put  the  patient  to  bed  and  use 
sand-bags  (as  in  fracture  of  the  hip)  for  four  weeks.  We 
may  tie  the  knees  together  instead  of  using  the  sand-bags. 
Passive  motion  is  made  in  the  third  week.  The  pulleys  must 
not  be  used  in  reduction.  They  may  inflict  great  or  even 
fatal  injury.  If  the  surgeon  fails  to  reduce  the  deformity, 
there  are  two  courses  open  to  him.  He  may  leave  it  alone. 
He  may  operate.  If  he  leaves  it  alone,  the  limb  will  become 
ankylosed,  though  probably  useful.  Allis  thinks  the  dorsal 
region  will  be  the  best  place  to  leave  it.  If  he  determines 
to  operate,  he  must  recognize  that  tenotomy  is  useless.  It 
is  necessary  to  make  a  free  incision  in  order  to  restore  the 
bone. 

Dislocation  into  the  Sciatic  Notch. — In  this  dislocation 
the  head  of  the  bone  passes  backward  and  a  little  upward, 
and  rests  upon  the  ischium  at  the  margin  of  the  sciatic 
notch  (not  in  the  notch),  below  the  tendon 
of  the  obturator  internus  muscle.  The 
causes  are  the  same  as  those  given  for  the 
previous  dislocation. 

Signs. — The  signs  in  dislocation  into  the 
sciatic  notch  are  like  those  of  dislocation  upon 
the  dorsum  of  the  ilium,  but  they  are  not  so 
marked.  There  are  flattening  and  broaden- 
ing of  the  hip  ;  ascent  of  the  trochanter 
above  Nelaton's  line ;  shortening  to  the  ex- 
tent of  an  inch  ;  relaxation  of  the  fascia  lata. 
Allis's  sign  is  present,  that  is,  if  the  knee 
of  the  injured  side  is  vertical,  the  sole  of 
the  foot  touches  the  bed.  Flexion,  inward 
rotation,  and  adduction  exist,  but  the  axis 
of  the  femur  of  the  injured  side  passes 
through  the  knee  of  the  sound  side,  and 
the  ball  of  the  great  toe  of  the  injured  side  rests  upon  the 
great  toe  of  the  sound  side  (Fig.   i86).      Other  symptoms 


Fig.  i86. — Hip-joint 
dislocation:  back- 
ward, or  into  the  sci- 
atic notch  (Cooper). 


DISLOCATION  OF   THE   FEMUR.  575 

are  identical  with  those  of  dislocation  upon  the  dorsum  of 
the  iHum,  but  are  less  pronounced.  AUis's  signs  of  this 
dislocation  are  of  value :  if,  with  the  patient  recumbent,  the 
thighs  are  brought  to  a  right  angle  with  the  body,  shorten- 
ing^on  the  affected  side  is  materially  increased ;  if  the  dislo- 
cated thigh  is  extended,  the  back  arches  as  in  hip  disease. 

Diagnosis  and  Treatment. — The  signs  of  dislocation  into 
the  sciatic  notch  are  similar  to,  but  are  less  marked  than, 
those  of  dorsal  dislocation,  and,  being  a  backward  disloca- 
tion, the  reduction  and  treatment  are  the  same  as  for  dis- 
location backward  upon  the  dorsum  of  the  ilium. 

Dislocation  Downward  into  the  Obturator  Foramen. — 
Downward  dislocation  is  the  primary  position  of  most  dislo- 
cations of  the  hip,  the  bone  rarely  remaining  in  the  thyroid 
foramen,  but  usually  mounting  up  as  a  result  of  muscular 
action  or  of  the  initial  violence.  The  cause  is  violent  abduc- 
tion bv  falls  or  by  stepping  from  a  moving  car. 

Signs. — Dislocation  downward  into  the  obturator  foramen 
is  indicated  by  flattening  of  the  hip  ;  the  head  of  the  bone 
is  felt  in  its  new  position  and  is  missed  from  the  acetabulum ; 
rigidit\^  exists  ;  passive  motion  is  only  possible  in  the  direc- 
tion of  deformity,  and  that  to  a  slight  extent ;  a  hollow  is 
noted  over  the  great  trochanter,  which  process  is  \vell  below 
Nelaton's  line  and  nearer  than  normal  to  the  middle  line. 
There  is  a  depression  from  relaxed  muscles  and  fascia  noted 
between  the  ilium  and  femur.  The  gluteal  crease  is  lower 
than  is  the  crease  of  the  opposite  side ;  there  is  lengthening 
to  the  extent  of  one  to  two  inches  ;  the  body  is  bent  forward 
by  the  traction  upon  the  psoas  and  iliacus  muscles,  and  is  also 
deviated  to  the  side,  thus  causing  great  apparent  lengthening  ; 
the  limb  is  advanced  partially  flexed  and  abducted,  and  the 
foot  is  pointed  straight  ahead  or  is  a  little  everted  (Fig.  1 87 ) ; 
when  the  patient  is  recumbent  extension  is  impossible,  the 
knees  cannot  be  pushed  together  without  great  pain,  and  the 
abductor  muscles  are  hard  and  rigid.  AUis's  sign  is  absent. 
Unreduced  dislocations  do  well,  the  patient  obtaining  a  very 
useful  hip-joint  (Sedillot). 

Treatment. — In  treating  dislocation  downward  into  the 
obturator  foramen  give  ether  and  effect  reduction  if  possible 
by  manipulation,  and,  if  this  fails,  by  extension.  To  reduce 
by  manipulation,  flex  the  leg  on  the  thigh  and  the  thigh 
on  the  pelvis,  and  then  perform,  in  the  following  order, 
abduction,  internal  circumduction,  and  extension.  Allis's 
rule  of  reduction  is  as  follows  :  flex  the  pelvis  to  the  floor ; 
pull  the  head  outward  and  above  the  socket;  fix  the  head; 


5/6   DISEASES  AND  INJURIES    OF  BONES  AND  JOINTS. 

push  knee  toward  sound  knee ;  extend  femur.  If  extension 
is  made,  make  traction  in  the  axis  of  the  Hmb  by  means  of 
musHn  fastened  around  the  thigh  by  a  clove-hitch.  Do  not 
use  the  pulleys  ;  operate  rather  than  use  them. 

Dislocation  upon  the  pubis  is  very  rare.     The  head  of 
the  bone  usually  rests  just  internal  to  the  anterior  inferior 


Fig.  187.— Hip-joint  dislocation  :  down- 
ward into  the  obtutator  or  thyroid  fora- 
men (Cooper). 


Fig. 


-Dislocation  on  the  pubis 
(Cooper'). 


spine  of  the  ilium.  The  primary  position  of  the  bone  is  in 
the  thyroid  foramen  ;  the  pubic  dislocation,  when  it  occurs, 
is  always  secondary,  and  is  due  to  the  initial  force  and  to 
muscular  action. 

Symptoms. — In  pubic  dislocation  the  head  of  the  bone  can 
be  felt  and  seen  in  its  new  position  ;  the  hip  is  flattened ; 
there  is  a  hollow  over  the  great  trochanter,  this  process 
being  found  below  the  anterior  superior  spine  of  the  ilium ; 
there  is  shortening  to  the  extent  of  an  inch ;  the  limb  is  in 
abduction  with  eversion  (Fig.  188),  and  the  knees  cannot  be 
approximated  without  great  pain.  When  the  knee  is  per- 
pendicular the  foot  of  the  injured  side  touches  the  foot  of 
the  bed. 

Treatment. — In  the  treatment  of  pubic  dislocation  give 
ether  and  employ  manipulation  as  for  thyroid  dislocation. 
If  this  fails,  employ  extension.  The  limb  is  well  abducted, 
extension  is  made  downward  and  backward,  and  the  head 
of  the  femur  is  pulled  outward  "  by  a  towel  around  the  thigh, 
just  beneath  the  groin"  (Keetley).  The  after-treatment  is  the 
same  as  that  for  the  previous  forms. 

Anomalous  Dislocations  of  the  Hip. —  In  supraspinous 
dislocation  the  dislocation  of  the  hip  is  backward,  the  head 


DISLOCATION  OF   THE   FEJMrR.  577 

of  the  femur  resting  upon  the  ilium  above  or  even  anterior 
to  the  anterior  superior  spine.  In  ischial  dislocation  the  dis- 
location is  downward  and  backward,  the  head  of  the  femur 
resting  on  the  ischial  tuberosity  or  in  the  lesser  sciatic  notch. 
Moiiteo-gias  dislocation  is  a  supraspinous  dislocation  with 
eversion  of  the  limb.  In  perineal  dislocation  the  head  of  the 
femur  is  in  the  perineum.  In  snprap2ibic  dislocation  the  head 
of  the  femur  passes  above  the  pubes.  In  subspinous  disloca- 
tion the  femoral  head  rests  on  the  horizontal  ramus  of  the 
pubes. 

Dislocation  "with  Catching-  Up  of  Sciatic  Nerve  upon 
Reduction. — This  accident  causes  severe  pain.  The  leg  is 
flexed  on  the  thigh  and  the  thigh  is  flexed  on  the  pelvis. 
Allis  tells  us  that  the  task  of  reduction  is  very  unpromising. 
We  must  strive  to  put  the  neck  of  the  femur  in  such  a 
position  that  the  nerve  will  "  drop  off,"  and  yet  often  the 
nerve  cannot  drop  off  because  it  is  held  by  adhesion  to  the 
injured  muscles.  Allis  attempts  reduction  by  the  following 
plan  : 

1.  Place  the  patient  upon  his  back  and  redislocate  the 
femur. 

2.  Extend  the  thigh. 

3.  Flex  the  leg  on  the  thigh. 

4.  Turn  ankle  out  until  the  leg  is  horizontal  (this  causes 
the  head  to  look  downward). 

5.  "Shake,  shock,  jar,  adduct  and  abduct,"  to  disengage 
the  nerve. 

6.  Rotate  into  socket  without  flexing  the  leg  (without 
making  the  nerve  tense). 

7.  If  this  fails,  make  an  incision  above  the  popliteal  space, 
and  draw  the  nerve  out  of  the  wound.  Detach  the  head 
from  its  entanglement  and  rotate  it  into  the  socket. 

Dislocation  of  Head  of  Femur  "with  Fracture  of  Shaft. 
— We  may  incise  and  replace  and  wire  the  fragments.  We 
may  use  McBurney's  hooks  as  in  the  shoulder.  We  may 
be  forced  to  do  a  resection  of  the  head. 

Allis  maintains  that  it  is  possible  to  reduce  it  by  manipu- 
lation. He  states  that  the  upper  fragment  is  the  entire  lever, 
and  the  lower  fragment  "  is  only  the  agent  through  \vhich 
we  apply  our  force."  The  fragments  are  not  completely 
separated,  but  are  connected  at  one  side  by  material  which 
is  "  partly  periosteal,  partly  tendinous,  and  partly  muscular." 
This  connecting  material  enables  us  to  make  traction  upon 
the  upper  fragment,  but  does  not  allow  "  rotation,  circum- 
duction, and  leverage  through  the  agency  of  the  lower  frag- 
37 


5/8    DISEASES  AND   INJURIES   OE  BONES  AND  JOINTS. 

ment."  Hence  "  the  only  agency  at  our  command  is  trac- 
tion." If  the  dislocation  is  inward  (forward),  draw  the  head 
outward  and  have  an  assistant  make  direct  pressure  upon 
the  head.  If  this  fails,  the  assistant  holds  the  head  to  pre- 
vent its  slipping  into  the  thyroid  depression,  and  the  surgeon 
makes  traction  inward  or  inward  and  downward.  If  the 
dislocation  is  outward  (backward),  make  traction  directly 
upward  to  lift  the  head  to  the  level  of  the  socket,  and  try  to 
place  the  head  over  the  socket  by  traction  obliquely  upward 
and  inward.  During  all  these  manipulations  an  assistant 
presses  upon  the  trochanter  to  prevent  the  head  slipping 
back.  Traction  is  now  made  downward  and  inward,  and  the 
tightened  ligament  drags  the  head  into  place. 

Dislocations  of  the  Knee. — These  dislocations  are  rare. 
There  are  four  forms — forward,  backward,  inward,  and  out- 
ward. They  may  be  complete  or  be  incomplete ;  the  com- 
monest dislocations  are  lateral.  The  cause  is  violent  force, 
such  as  a  fall,  or  in  jumping  from  a  moving  train,  or  in 
being  caught  by  the  foot  and  dragged. 

Dislocation  Forward  of  the  Knee-joint. — In  the  com- 
plete form  of  forward  dislocation  the  deformity  is  obvious. 
The  limb  is  usually  extended,  but  it  may  be  flexed.  Much 
shortening  exists  ;  the  condyles  are  felt  posterior  and  below ; 
the  head  of  the  tibia  is  felt  anterior  and  above ;  the  patella  is 
movable  and  the  quadriceps  is  lax ;  pressure  of  the  condyles 
upon  the  contents  of  the  popliteal  space  arrests  the  tibial 
pulse  and  causes  edema  and  intense  pain.  In  incomplete 
dislocation  the  symptoms  are  identical  in  kind,  but  are  less 
pronounced. 

Treatment. — Compound  dislocation  of  the  knee-joint  often 
demands  excision  or  amputation.  In  simple  dislocation  give 
ether,  have  one  assistant  extend  the  leg  while  another  makes 
counter-extension  on  the  thigh,  and  the  surgeon  pushes  the 
bone  into  place.  Reduction  is  easy  because  of  ligamentous 
laceration.  Place  the  limb  on  a  double  inclined  plane,  and 
combat  inflammation  by  the  usual  methods  (see  Synovitis, 
page  510).  Begin  passive  motion  in  the  third  week.  The 
patient  must  wear  a  knee-support  for  months.  If  the  pop- 
hteal  vessels  are  much  damaged,  gangrene  will  supervene 
and  amputation  will  be  demanded. 

Dislocation  Backward,  of  the  Knee-joint. — In  the  com- 
plete form  of  knee-joint  dislocation  backward  displacement 
is  not  so  great  as  in  dislocation  forward.  The  head  of  the 
tibia  projects  posteriorly  and  above,  the  femoral  condyles 
anteriorly  and  below ;   the   leg  is,  as  a  rule,  partly  flexed, 


DISLOCATIOX  OF   THE   PATELLA.  579 

but  it  may  be  extended,  and  there  is  moderate  shortening. 
In  incomplete  dislocation  the  symptoms  are  less  marked. 

Treatment. — The  treatment  of  backward  dislocation  of  the 
knee-joint  is  the  same  as  for  forward  dislocation. 

Dislocation  Out^vard  of  the  Knee-joint. — Is  usually  in- 
complete. The  niner  tuberosity  of  the  tibia  in  outward  dis- 
location lies  upon  the  outer  condyle  of  the  femur  (Pick) ;  the 
inner  condyle  of  the  femur  projects  internally ;  the  outer 
tibial  tuberosity  and  fibular  he^td  project  externally,  the  former 
having  a  depression  below  it,  and  the  latter  abo\'e  it ;  the  leg 
is  semiflexed,  but  shortening  is  absent. 

Dislocation  Inward  of  the  Knee-joint. — Is  usually  incom- 
plete. The  outer  tuberosity  of  the  tibia  in  inward  dislocation 
lies  upon  the  inner  condyle  of  the  femur ;  the  outer  condyle 
of  the  femur  forms  an  external  prominence,  and  the  inner 
tuberosity  of  the  tibia  forms  an  internal  prominence.  Pick 
cautions  us  not  to  mistake  a  separation  of  the  lower  femoral 
epiphysis  for  lateral  dislocation  (the  former  is  reduced  easily, 
the  deformit)^  tends  to  recur,  and  there  is  soft  crepitus). 

Treatment. — In  treating  lateral  dislocation  of  the  knee- 
joint,  effect  extension  and  counter-extension  as  in  antero- 
posterior dislocations.  The  leg  is  moved  from  side  to  side 
and  attempts  are  made  at  rotation.  The  after-treatment  is 
the  same  as  that  for  anteroposterior  luxations. 

Dislocations  of  the  Patella. — Are  usually  acquired. 
There  are  thirty-five  congenital  cases  on  record  (Bajardi). 
There  are  three  forms :  outward,  inward,  and  edgewise. 
The  so-called  dislocation  upward  is  in  reality  rupture  of  the 
ligamentum  patellae  (page  618). 

Dislocation  outward  may  be  due  to  muscular  action  or 
to  direct  force,  and  occurs  during  extension  of  the  leg.  It 
occasionally  happens  in  a  person  with  knock-knees.  If  the 
dislocation  is  complete,  the  bone  Hes  upon  the  external  sur- 
face of  the  external  condyle  ;  if  incomplete,  the  patella  rests 
upon  the  anterior  surface  of  the  external  condyle.  The  leg 
is  extended,  flexion  is  impossible,  and  attempts  at  flexion 
produce  great  agony.  The  knee  is  wider  than  normal. 
There  is  a  hollow  in  front  of  the  joint.  The  bone  is  felt 
in  its  new  position. 

Dislocation  inward  is  extremely  rare.  The  signs  of  this 
dislocation  are  hke  the  signs  of  dislocation. outward,  except 
that  the  patella  rests  upon  the  inner  condyle. 

Treatment. — Give  ether.  Raise  the  body  upon  a  bed-rest, 
and  flex  the  thigh.  Grasp  the  patella,  depress  the  margin 
of  the  patella  which  is  farthest  from  the  center  of  the  joint 


580   DISEASES  AXD   IXJ CRIES    OE  BOXES  AND  JOINTS. 

(Pick).  The  muscles  pull  the  bone  into  place.  Immobilize 
for  three  weeks,  when  passive  motion  is  begun.  Incision 
may  be  necessary  in  order  to  effect  reduction. 

Dislocation  of  the  Patella  Edgewise. — The  patella  rotates 
vertically,  one  edge  resting  between  the  condyles.  As  a  rule, 
the  outer  border  is  in  the  intercondyloid  notch  (Pick).  This 
condition  is  produced  by  direct  force  when  the  extremity  is 
partly  flexed.  Twisting  and  muscular  action  have  been 
assigned  as  causes.     The  condition  is  obviously  manifest. 

Treatment. — Give  ether.  Pick  recommends  "  sudden  and 
forcible  bending  of  the  knee."  In  some  cases  the  bone  can 
be  pushed  into  place,  the  limb  being  extended  and  flexed  as 
in  the  reduction  of  a  lateral  dislocation.  In  some  cases 
incision  will  be  necessary. 

Dislocation  of  the  Semilunar  Cartilages  of  the  Knee 
(the  Internal  Derangement  of  Hey;  Subluxation  of  the 
Knee-joint). — These  interarticular  cartilages  are  attached 
in  front  of  and  behind  the  tibial  spine,  and  their  convexity 
is  attached  to  the  edge  of  the  tibial  tuberosities  by  the  coro- 
nary ligament.  The  inner  cartilage  is  connected  with  the 
internal  lateral  ligament,  and  it  has  a  moderate  freedom 
of  movement;  the  outer  cartilage  is  not  connected  with 
the  external  lateral  ligament,  and  is  not  freely  movable, 
yet  the  outer  is  more  often  dislocated  than  is  the  inner 
cartilage.  People  who  kneel  much  are  predisposed  to 
this  accident  (Annandale).  The  cause  is  a  twist  when  the 
knee  is  flexed,  as  in  stubbing  the  toe. 

Symptoms. — The  indications  of  interarticular-cartilage  dis- 
location are  a  sudden,  violent,  sickening  pain  in  the  knee, 
that  may  cause  the  patient  to  fall ;  the  position  is  one  of 
fixed  semiflexion,  voluntary  motion  being  impossible  and 
passive  motion  causing  fierce  pain  ;  a  displacement  of  either 
cartilage  away  from  the  tibial  spine  produces  a  prominence 
on  one  or  the  other  side  of  the  knee-joint,  and  a  displace- 
ment toward  the  tibial  spine  makes  a  prominence  on  one  side 
of  the  ligament  of  the  patella.  Subluxation  is  soon  followed 
by  inflammation  of  the  cartilages  and  of  the  joint,  and  swell- 
ing rapidly  masks  the  projection.  This  accident  is  usually 
mistaken  for  blocking  of  the  joint  by  a  floating  cartilage. 
One  point  in  diagnosis  is  that  a  loose  cartilage  changes  its 
position,  but  a  dislocated  cartilage  remains  always  in  the  same 
position  (Turner). 

Treatvient. — In  treating  dislocation  of  the  semilunar  carti- 
lages of  the  knee  give  ether  and  reduce  by  forced  flexion  and 
sudden  extension  with  rotation,  at  the  same  time  endeavor- 
ing to  push  the  projecting  cartilage  into  place.     After  reduc- 


DISLOCATIOX   OF   THE   AXKLE-JOfXT.  58 1 

tion  combat  inflammation,  apply  a  splint,  and  use  the  proper 
remedies  for  one  week  (see  Synovitis),  then  begin  passive 
motion.  As  recurrence  of  the  displacement  is  usual,  the 
patient  should  wear  a  knee-cap  for  a  year  or  more.  If 
reduction  is  impossible,  persistent  passive  motion  will  usu- 
ally secure  a  useful  joint.  In  intractable  cases  incise  and 
stitch  the  cartilages  or  remove  the  loosened  portion  (Annan- 
dale). 

Dislocations  of  the  Fibula  :  Dislocation  at  the  Supe- 
rior Tibiofibular  Articulation. — This  injun-  is  rare.  The 
head  of  the  fibula  may  go  forward  or  backward.  The  causes 
are  direct  force  and  violent  adduction  of  the  foot  with  abduc- 
tion of  the  knee  (Bryant). 

Symptoms. — In  dislocation  of  the  fibula  the  position  is  one 
of  semiflexion,  voluntary  extension  and  flexion  being  impaired 
or  lost.  A  distinct  movable  projection  is  readily  noticed  in 
front  or  behind,  which  is  found  to  be  continuous  with  the 
fibula.  There  is  a  depression  over  the  normal  position  of  the 
head  of  the  fibula. 

Treatment. — In  treating  dislocation  of  the  fibula  bend  the 
knee  to  relax  the  biceps,  and  proceed  to  push  the  bone  into 
place.  Put  a  compress  over  the  head  of  the  fibula,  apply  a 
bandage,  and  put  the  limb  on  a  double  inclined  plane  for  three 
weeks!'  At  the  end  of  this  time  put  a  lacing  knee-support 
upon  the  knee  and  let  the  patient  up.  Displacement  being 
liable  to  recur,  a  knee-cap  must  be  worn  for  a  year. 

Dislocations  of  the  Ankle-joint.— These  injuries  are  not 
unusual.  Fracture  is  a  frequent  complication.  _  There  are 
five  forms  of  ankle-joint  dislocation — outward,  imvard,  for- 
Avard.  backward,  and  upward. 

Lateral  dislocations  of  the  ankle-joint  are  either  outward 
or  inward,  and  mav  be  complete  or  incomplete.  In  these 
dislocations  the  astragalus  rotates.  In  incomplete  dislocations 
"  there  is  no  great  separation  of  the  trochlear  surface  of  the 
astragalus  from  the  under  surface  of  the  tibia,  but  the  outer 
or  inner  margin  of  this  surface  is  brought  into  contact  with 
the  articular  surface  of  the  tibia,  and  the  whole  foot  presents 
a  lateral  twist"  (Pick).  The  causes  of  these  dislocations  are 
twists  of  the  joint. 

5j';;///^;//.9.— Incomplete  outward  dislocation  of  the  ankle- 
joint  is  known  as  Potfs  fracture  (see  page  505).  Complete 
outward  dislocation,  in  which  the  articular  surface  of  the 
astragalus  is  completely  displaced  outward  from  the  articular 
surface  of  the  tibia,  and  which  condition  is  associated  with  a 
fracture  of  the  fibula  and  separation  of  the  inferior  tibiofibu- 


582    D/SEASES  AXD    I XJ CRIES    OE  BOXES   AXD  JOIXTS. 

lar  articulation,  is  known  as  Dtipiiytren' s  fracture.  In  incom- 
plete dislocation  the  foot  goes  outward  and  upward,  the  fibula 
is  fractured,  and  the  tibiofibular  ligaments  are  torn  off.  In 
Dupuytren's  fracture  the  ankle  is  broad,  the  inner  malleolus 
projects  and  looks  lower  than  natural,  the  outer  malleolus 
ascends  with  the  foot,  the  foot  rotates  outward,  and  crepitus 
can  be  found.  In  inward  dislocation  which  is  associated  with 
fracture  of  the  inner  malleolus  there  is  inversion,  the  outer 
malleolus  projects,  and  crepitus  can  be  found.  In  incom- 
plete separation  the  symptoms  are  similar,  but  are  not  so 
marked. 

Treatment. — In  treating  a  case  of  dislocation  of  the  ankle- 
joint  the  deformity  is  reduced  by  flexing  the  leg  on  the  thigh 
and  the  thigh  on  the  pelvis ;  an  assistant  makes  counter-ex- 
tension from  the  knee  ;  the  surgeon  makes  extension  from  the 
foot,  and  at  the  same  time  rocks  the  astragalus  into  place. 
Dupuytren's  fracture  is  treated  in  the  same  manner  as  Pott's 
fracture  (page  505).  Dislocation  inward  is  treated  in  a  fract- 
ure-box for  the  same  period  as  Pott's  fracture. 

Anteroposterior  dislocations  of  the  ankleTJoint  are  rare. 
The  cause  is  the  catching  of  the  foot  in  jumping  or  falling — 
direct  violence.  In  dislocation  forward  the  foot  is  lengthened, 
the  heel  is  not  conspicuous,  the  tibia  and  fibula  project  against 
the  tendo  Achillis,  and  the  relation  of  the  malleoli  to  the 
tarsus  is  altered.  In  incomplete  dislocation  the  symptoms 
are  similar,  but  less  pronounced.  In  dislocation  backward 
the  foot  is  shortened,  the  tibia  and  fibula  project  in  front,  the 
heel  is  prominent,  and  the  relation  between  the  malleoli  and 
the  tarsus  is  altered.  In  incomplete  dislocation  the  symp- 
toms are  similar,  but  less  marked. 

Treatment. — In  anteroposterior  dislocation  of  the  ankle- 
joint,  reduce  as  in  lateral  dislocations.  Sometimes  the  tendo 
Achillis  must  be  cut.  Apply  a  silicate-of-sodium  dressing, 
and  let  it  be  worn  for  two  weeks  ;  then  begin  passive  motion, 
and  let  the  patient  wear  side-splints  for  a  week  longer. 

Dislocation  upward  of  the  ankle-joint,  or  Nelaton's 
dislocation,  is  a  very  rare  injury.  The  astragalus  is  wedged 
between  the  widely  separated  tibia  and  fibula.  This  dislo- 
cation is  usually  associated  with  fracture.  The  cause  is  a 
fall  upon  the  feet  from  a  great  height. 

Symptoms. — Upward  dislocation  of  the  ankle-joint  is  indi- 
cated by  the  widening  of  the  ankle  and  by  the  flattening  of 
the  foot.  The  malleoli  are  nearly  on  a  level  with  the  plantar 
surface  of  the  foot,  and  there  is  absolute  rigidity. 

Treatment. — In  treating  upward  dislocation  of  the  ankle- 


DISLOCATION   OF    THE   ASTRAGALUS.  583 

joint  give  ether,  and  try  to  reduce  by  powerful  extension  and 
counter-extension.  Treat  the  injury  afterward  in  the  same 
manner  as  for  an  anteroposterior  luxation. 

Dislocation  of  the  Astragalus. — The  astragalus  may  be 
displaced  from  the  bones  of  the  leg  and  at  the  same  time  be 
separated  from  the  rest  of  the  tarsus.  The  displacement  may 
be  forward,  backward,  outward,  inward,  or  rotary. 

Dislocation  of  the  astragalus  forward  or  backward  is 
caused  by  falls  or  twists. 

Symptoms. — In  forward  dislocation  the  astragalus  projects 
strongly ;  there  is  shortening  of  the  foot,  and  the  malleoli 
approach  the  plantar  aspect  of  the  foot ;  the  foot  is  deviated 
to  one  side  or  to  the  other,  and  there  is  absolute  rigidity  of 
the  ankle-joint.  In  incomplete  luxations  the  symptoms  are 
similar,  but  less  marked.  This  dislocation  may  be  obliquely 
forward.  In  backward  dislocation  of  the  astragalus  the  foot 
is  not  deviated  to  either  side  ;  the  astragalus  projects  between 
the  malleoli  and  above  the  os  calcis,  and  the  tendo  Achillis  is 
stretched  over  the  projection.  Rigidity  is  absolute.  This 
dislocation  may  be  obliquely  backward. 

Lateral  and  Rotary  Dislocations  of  the  Astragalus. — 
Lateral  dislocations  of  the  astragalus  are  rare,  are  always 
compound,  and  are  always  associated  with  fracture.  In  rotary 
dislocation  the  astragalus  remains  in  its  normal  habitat  after 
rotating  on  its  own  axis,  either  horizontal  or  vertical.  The 
causes  of  rotary  dislocation  are  twists  of  the  foot  when  it  is 
at  a  right  angle  to  the  leg  (Barwell).  The  symptoms  of  rotary 
dislocations  are  obscure.  There  is  rigidity,  but  sometimes 
portions  of  the  astragalus  may  be  made  out. 

Treatment  of  Dislocations  of  the  Astragalus. — In  treating 
astragalus  dislocation  reduce  under  ether  by  flexing  the 
knee  to  relax  the  gastrocnemius,  extending  the  foot,  and 
pushing  the  bone  into  place.  It  may  be  necessary  to  cut 
the  tendo  Achillis.  After  reduction  put  up  the  foot  and  leg 
in  silicate-of-sodium  dressing  for  two  weeks,  and  then  begin 
passive  motion  and  apply  side-splints,  which  are  to  be  worn 
for  one  week  more.  If  reduction  fails,  support  the  limb  on 
splints,  combat  inflammation,  and  endeavor  to  bring  about 
union  between  the  dislocated  bone  and  the  tissues.  Often, 
in  unreduced  dislocation,  the  skin  sloughs  over  the  project- 
ing bone.  Excision  is  demanded  the  moment  sloughing  is 
seen  to  be  inevitable.  Cases  of  compound  dislocation  of  the 
astragalus  require  immediate  excision. 

Subastragaloid  Dislocation. — This  condition  is  a  sepa- 
ration of  the   astragalus   from   the   os   calcis   and   scaphoid, 


584   DISEASES  AXD   L\J CRIES    OF  BONES  AND  JOINTS. 

without  separation  of  the  astragalus  from  the  bones  of 
the  leg.  Pick  states  that  the  usual  classification  for  these 
dislocations  is  forward,  backward,  inward,  and  outward,  but 
that  the  displacement  is,  as  a  rule,  oblique,  the  foot  pass- 
ing backward  and  outward  or  backward  and  inward.  The 
causes  are  twists. 

SyiuptoDis. — In  subastragaloid  dislocation  the  astragalus 
projects  on  the  dorsum ;  the  foot  is  everted  in  outward  dis- 
location and  inverted  in  inward  dislocation  ;  the  relation  of 
the  malleoli  to  the  astragalus  is  unaltered ;  the  ankle-joint  is 
not  absolutely  rigid ;  the  foot  "  is  shortened  in  front  and  is 
elongated  behind  "  (Pick). 

Treatment. — To  treat  subastragaloid  dislocation  make 
extension  in  the  direction  opposite  to  that  of  the  displace- 
ment. In  dislocation  of  the  tarsus  backward  fix  a  bandage 
around  the  foot,  on  a  level  with  the  heads  of  the  metatarsal 
bones,  which  bandage  the  surgeon  ties  around  his  shoulders. 
The  surgeon  puts  one  knee  in  front  of  the  angle  and  thus 
fixes  the  leg,  raises  himself  up  to  make  extension  upon  the 
tarsus,  and  moulds  the  bone  into  position.  Tenotomy  may 
be  necessary.  After  reduction  apply  a  silicate  dressing  for 
three  weeks.  The  ankle-joint,  fortunately,  is  not  involved, 
and  stiffness  of  this  articulation  need  not  be  apprehended. 
If  reduction  is  impossible,  take  the  same  course  as  in  luxa- 
tions of  the  astragalus. 

Dislocations  of  the  other  tarsal  bones  are  very  rare. 
Single  bones  may  be  dislocated,  or  the  luxation  may  occur 
at  the  mediotarsal  articulation. 

Symptoms  and  Treatment. — Projection  is  an  obvious 
symptom  in  dislocation  of  the  other  tarsal  bones.  The 
treatment  is  to  reduce  by  extension  and  moulding,  the  part 
being  put  up  in  silicate-of-sodium  dressing  for  two  weeks. 

Dislocations  of  the  metatarsal  bones  are  rare. 

Symptoms  and  Treatment. — Shortening  of  the  toes  and 
projection  of  the  dislocated  bone  are  symptoms  of  disloca- 
tion of  the  metatarsal  bones.  To  treat  these  dislocations 
reduce  by  extension  under  ether  and  put  up  in  a  silicate 
dressing  for  two  weeks.  If  reduction  fails,  the  functions  of 
the  foot  will  not  be  much  impaired. 

Dislocations  of  the  phalanges  are  veiy  rare.  The 
first  phalanx  of  the  big  toe  is  the  one  most  liable  to  dislo- 
cation. 

Symptoms  and  Treatment. — Dislocations  of  the  phalanges 
are  obvious.  The  treatment  is  by  reduction  as  in  dislocations 
of  the  thumb.     Immobilize  for  two  weeks. 


OSTEOTOMY. 


5«: 


5.  Operations  upon  Bones. 

Osteotomy. — By  the  term  osteotomy  the  modern  surgeon 
TTieans  hterally  the  sectioning  of  a  bone  for  the  purpose  of 
straightening  a  hmb  ankylosed  in  a  bad  position,  correcting 
a  bony  deformity,  or  amending  a  vicious  union  of  a  fracture. 
In  a  linear  osteotomy  the  bone  is  transversely  divided  in  one 
spot ;  in  a  cuneiform  osteotomy  a  wedge-shaped  portion  of 
bone  is  remov^ed.  The  operation  of  osteotomy  may  be  per- 
formed with  a  saw  (Fig.  1 89)  or  with  an  osteotome.  The  saw 
creates  dust,  draws  much  air  into  the  wound,  and  lacerates 
the  tissues  to  a  considei-able  degree.  Most  surgeons  prefer 
the  chisel  or  the  osteotome.  The  osteotome  slopes  down  to 
a  point  from  each  side  (Fig.  190) ;  the  chisel  is  straight  on  one 
side  and  on  the  other  is  bevelled  to  a  point. 

Osteotomy  for  Genu  Valgum,  or  Knock-knee  (Macewen's 
Operation,  Fig.  192). — In  this  operation  the  instruments  re- 


FiG.  190. — Osteotome. 


Fig.  191. — Rawhide  mallet. 


quired  are  the  scalpel,  hemostatic  forceps,  osteotomes  of  sev- 
eral sizes,  a  mallet  (Fig.  19 1),  and  a  sand-bag  wrapped  in  an 
aseptic  towel. 

Operation. — The  patient  lies  upon  his  back,  being  rolled  a 
little  toward  the  diseased  side.  The  leg  of  the  diseased  .side  is 
partly  flexed  upon  the  thigh  and  the  thigh  upon  the  pelvis, 
and  the  extremity  is  laid  upon  its  outer  surface,  the  sand-bag 
being  pushed  between  the  extremity  and  the  bed,  opposite  to 
the  site  of  section.  The  flexion  of  the  knee  relaxes  the 
popliteal  vessels  and  saves  them  from  injury.  The  surgeon, 
if   operating  on   the  right  leg,   stands   outside  of   that   ex- 


586   DISEASES  AXD   IXJURIES    OE  BONES  AND  JOINTS. 


tremity ;  if  operating  on  the  left  leg,  he  stands  opposite  the 
left  hip  (Barker).  Enter  the  knife  at  the  inner  side  of  the 
knee,  just  in  front  of  the  adductor  tubercle  of  the  inner  con- 
dyle and  on  a  level  with  the  upper  border  of  "  the  patellar 
articular  surface  of  the  femur"  (Barker) ;  cut  down  to  the 
bone,  and  make  an  incision  upward  one  inch  in  length,  in 
the  direction  of  the  axis  of  the 
femur.  At  the  lower  angle 
of  this  wound  insert  an  osteo- 
tome and  turn   it   to   a   right 


Fig.  192. — Osteotomy  of  the  right 
femur  in  a  case  of  knock-knee  :  A  B, 
epiphyseal  line;  c,  section  of  Mac- 
ewen  ;   D  E,  section  of  Ogston. 


Fig.  193. — Macewen's  operation  for  genu  val- 
gum :  the  chisel  is  held  in  the  line  for  striking 
with  a  mallet ;  the  arrow  shows  the  direction  in 
which  the  chisel  is  levered  up  and  down  so  as  to 
make  a  wide  gap  in  the  bone  (after  Barker) . 


angle  with  the  shaft,  half  an  inch  above  the  epiphysis  (Fig. 
192) ;  strike  the  osteotome  several  times  with  a  mallet ;  move 
the  handle  several  times  toward  and  from  the  body,  so  as  to 
widen  the  cut  in  the  bone  (Fig.  193) ;  strike  the  osteotome 
again  several  times,  move  it  again,  and  continue  this  process 
until  the  bone  is  cut  one-third  through.  If  the  osteotome 
becomes  tightly  fixed,  withdraw  it  and  introduce  a  smaller 
one.  When  the  bone  is  cut  two-thirds  through  withdraw 
the  osteotome,  hold  a  piece  of  wet  antiseptic  gauze  over  the 
opening,  and  fracture  the  femur  by  strong  adduction.  Do 
not  suture  nor  drain  the  wound,  but  dress  it  antiseptically, 
wrap  the  entire  extremity  in  cotton,  and  apply  a  plaster-of- 
Paris  dressing  up  to  the  groin.  This  dressing  may  be  re- 
moved in  two  weeks,  and  the  patient  may  subsequently  be 
treated  with  sand-bags,  as  for  an  ordinary  fracture  of  the  thigh, 
but  without  extension.  This  operation  is  scarcely  ever  fatal. 
Ogsions  OpcratioJi  (Fig.  192). — In  this  operation  the  inter- 
nal condyle  is  sawed  off  obliquely  with  an  Adams  saw — a 
proceeding  which  permits  the  straigthening  of  the  knee. 
The  objection  to  this  operation  is  that  it  opens  the  knee- 


OSTEOTOMY. 


587 


joint,  and  that  this  cavity  fills  up  more  or  less  with  a  mixture 
of  blood  and  bone-dust.  Macewen's  operation  is  decidedly 
the  safer. 

Osteotomy  for  a  Bent  Tibia. — In  this  operation  the  in- 
struments required  are  the  same  as  those  indicated  in  the 
above  operation.  The  tibia  is  divided  transversely  or 
obliquely  (linear  osteotomy),  or  a  wedge-shaped  piece  is 
removed  (cuneiform  osteotomy).  The  oblique  incision  is 
the  best.  If  the  convexity  of  the  tibial  curve  is  inward,  cut 
the  bone  from  above  downward  and  from  in  front  backward ; 
if  the  curve  is  forward,  section  the  bone  from  above  down- 
ward and  from  within  outward.  The  fibula  need  rarely  be 
interfered  with.  After  the  osteotomy  the  limb  is  treated 
just  as  it  would  be  for  an  ordinary  fracture. 

Osteotomy  for  Faulty  Ankylosis  of  the  Hip-joint. — 
This  operation  is  performed  in  order  to  allow  straightening 
of  a  limb  that  has  undergone  bony  ankylosis  in  a  faulty 
or  an  inconvenient  position.  In  some  cases  an  attempt  is 
made  to  obtain  a  movable  joint,  but  in  most  cases  the  sur- 
geon must  be  satisfied  with  an  ankylosis  in  extension.  Oste- 
otomy may  be  performed  through  the  neck  of  the  femur  or 
through  the  shaft  of  the  femur  below-  the  trochanters. 

Osteotomy  through  the  neck  of  the  femur  is  performed 
(i)  with  a  saw  (Adams's  operation)  or  (2)  with  an  osteotome. 

I.  Adams's  Operation  (Fig.  194). — In  this  operation  the 
instruments  required  are  a  scalpel,  hemostatic  forceps,  a 
long,  blunt-pointed  tenotome,  and  an  Adams  saw. 

Operation. — The  patient  lies  upon  his  sound  hip ;  the  sur- 
geon stands  upon  the  side  to  be  operated  upon,  and  back 
of  the  patient.  The  knife  is  entered  a 
finger's  breadth  above  the  great  trochanter, 
is  pushed  in  until  it  strikes  the  neck  of  the 
bone,  is  then  carried  across  the  front  of  and 
at  a  right  angle  with  the  neck,  and  is  with- 
drawn, enlarging  the  wound  in  the  soft 
parts,  as  it  emerges,  to  the  extent  of  an 
inch.  The  saw  is  now  introduced  and  the 
neck  is  entirely  divided.  After  the  osteot- 
omy dress  the  wound  antiseptically  and 
place  the  extremity  straight.  To  straighten 
the  limb  it  may  be  found  necessary  to  cut 
contracted  tendons  and  fascial  bands. 
Apply  the  weight-extension  apparatus  and 
the  sand-bags.  Begin  passive  movements 
from  the  start  if  a  movable  joint  is  desired ;  few  patients  can 


Fig.  194. — Osteotomy 
through  the  neck  of 
the  femur  :  A,  Adams's 
operation;  e,  Gant's 
operation. 


588   DISEASES  AND   INJURIES    Of  BONES  AND  JOINTS. 

tolerate  the  pain  necessary  to  bring  this  about.  If  it  is 
determined  to  aim  for  a  stiff  joint,  treat  the  case  as  an  intra- 
capsular fracture  would  be  treated. 

2.  Witli  an  Osteotome. — The  instruments  required  in  this 
operation  are  the  same  as  those  used  for  genu  valgum.  No 
sand-bag  is  required.  The  position  of  the  patient  is  the  same 
as  that  in  Adams's  operation.  An  incision  one  inch  long  is 
made,  starting  just  above  the  great  trochanter,  ascending  in 
the  axis  of  the  femoral  neck,  and  reaching  to  the  bone.  An 
osteotome  is  introduced,  is  turned  to  a  right  angle  with  the 
bone,  and  is  struck  with  a  mallet  until  the  bone  is  completely 
divided.  (It  is  not  to  be  divided  partially  and  then  broken.) 
The  after-treatment  is  the  same  as  that  for  Adams's  opera- 
tion. The  operation  with  the  osteotome  is  to  be  preferred  to 
that  by  the  saw. 

Osteotomy  of  the  Shaft  of  the  Femur  below  the  Tro- 
chanters (Gant's  Operation). — In  this  operation  (Fig.  194) 
the  saw  may  be  used,  but  the  osteotome  is  to  be  preferred. 
The  instruments  employed  are  the  same  as  those  used  for 
Adams's  operation,  plus  an  osteotome. 

Operation. — The  position  in  Gant's  is  like  that  in  Adams's 
operation.  A  longitudinal  incision  one  inch  long  is  made 
upon  the  outer  aspect  of  the  femur  and  on  a  level  with  the 
lesser  trochanter.  The  osteotome  is  inserted  and  the  bone 
is  completely  divided  below  the  lesser  trochanter.  The 
after-treatment  is  the  same  as  that  for  Adams's  operation. 
Gant's  operation  is  the  best  method  for  correcting  faulty 
position  in  bony  ankylosis,  and  Adams's  operation  can  only 
be  employed  in  those  cases  where  the  femur  still  has  a  neck 
which  practically  is  unchanged. 

Osteotomy  for  Faulty  Ankylosis  of  the  Knee-joint. — 
This  operation  is  performed  for  bony  ankylosis  of  a  knee  in 
a  position  of  flexion.  The  instruments  employed  are  the 
same  as  those  used  for  genu  valgum. 

Operation. — The  patient  lies  upon  his  back  with  his  thighs 
flat  upon  the  bed,  the  legs  hanging  over  the  end  of  the  bed. 
The  surgeon  stands  on  the  patient's  right  side.  Just  above 
the  patellar  articular  surface  upon  the  femur  a  transverse 
incision  is  made,  one  inch  in  length  and  reaching  to  the 
bone.  The  osteotome  is  introduced  and  the  bone  is  cut 
nearly  through.  The  leg  is  then  forcibly  extended.  Do  not 
extend  too  violently,  or  the  popliteal  vessels  may  be  injured. 
In  cases  where  the  structures  of  the  popliteal  space  are 
tense,  do  not  at  once  bring  the  leg  into  extension,  but  do 
so  gradually  by  means  of  weights.     The  wound  is   dressed 


OSTEOTOMY.  589 

aseptically,  and  the  extremity  is  placed  upon  a  double  inclined 
plane  and  is  treated  as  for  fracture  near  the  knee-joint. 

Osteotomy  for  vicious  union  of  a  fracture  is  performed  in 
case  of  angular  deformity,  and  is  carried  out  in  the  same  man- 
ner as  are  the  above  procedures.  It  is  best,  when  possible,  to 
enter  the  osteotome  upon  the  concavity  of  the  bent  bone,  so 
that  the  periosteum  will  not  rupture  when  extension  is  made, 
and  the  patient  will  in  consequence  gain  a  longer  limb. 

Osteotomy  for  Hallux  Valgus. — In  this  operation  a  linear 
osteotomy  is  made  through  the  neck  of  the  metatarsal  bone 
of  the  great  toe,  the  toe  is  forcibly  adducted,  and  a  splint  is 
applied  to  the  inside  of  the  foot  and  the  toe. 

Osteotomy  for  Talipes  Bquinovarus. — The  instruments 
required  in  this  operation  are  a  scalpel,  hemostatic  forceps, 
a  narrow,  blunt-pointed  saw,  special  directors,  bone-cutting 
forceps,  sequestrum-forceps,  and  scissors. 

Operation  (after  Barker). — The  patient  lies  upon  his  back, 
the  thigh  is  semiflexed,  the  knee  is  bent,  and  the  sole  of  the 
foot  rests  upon  the  table.  The  surgeon  stands  to  the  right 
side  if  it  is  the  right  limb  to  be  operated  upon,  or  to  the  left 
side  if  it  is  the  left  limb.  Feel  for  the  outer  surface  of  the  cu- 
boid bone,  and  cut  away  from  over  the  latter  a  piece  of  skin 
corresponding  in  size  with  the  bone-wedge  intended  to  be 
removed  (this  piece  of  skin  must  include  the  bursa  which 
forms  in  these  cases).  Turn  the  foot  outward,  find  the 
astragaloscaphoid  articulation,  over  Avhich  make  an  incision 
"  from  the  lower  to  the  upper  dorsal  border  of  the  scaphoid 
bone  "  (Barker),  reaching  through  the  skin  only ;  place  the 
foot  again  in  the  first  position,  raise  all  the  soft  parts  from 
off  the  superior  surface  of  the  tarsus,  and  clear  a  triangular 
surface  corresponding  with  the  base  of  the  wedge  to  be 
removed;  pass  a  "kite-shaped"  director  (Fig.  195)  into  the 
external  wound,  and  cause  it  to  project  from  the  internal 
wound ;  push  the  saw  through  the  groove  of  the  director 
nearest  the  toes,  and  saw  through  the  tarsus,  from  the  dor- 
sum to  the  sole,  at  right  angles 
to  the  metatarsal  bones ;  push 
the  saw  through  the  groove  of 
the  director  nearest  the  ankle, 
and  saw  from  the  dorsum  to  the 

sole,   at    right     angles    to  the    long  Fig.  igs.-Davy-s  director  (Pye)T 

axis  of  the  calcaneum  ;  grasp  the 

wedge-shaped  piece  of  bone  with  sequestrum-forceps,  and 
cut  it  out  with  scissors,  with  bone-forceps,  or  with  a  blunt 
bistoury.     The  wound  is  well  irrigated,  the  foot  is  straight- 


590   DISEASES  AXD   INJURIES   OF  BOAES  AND  JOINTS. 


cned,  the  internal  wound  is  sewed  up,  the  external  wound  is 
sutured  except  at  its  lowest  portion,  where  a  drainage-tube 
is  to  be  retained  for  twenty-four  hours,  and  the  wound  is 
dressed  antiseptically.  The  foot  is  put  up  in  plaster  or  is  put 
upon  a  Davy  splint. 

Osteotomy  for  Talipes  Equinus. — This  operation  is  de- 
scribed by  Mr.  Davy,  who  devised  it,  as  follows  : '  "  Taking 
the  line  of  the  transverse  tarsal  joint  as  a  guide,  on  the  outer 
and  inner  sides  of  the  foot,  and  immediately  over  the  joint, 
two  wedge-shaped  pieces  of  skin  are  removed,  equal  in  extent 
to  the  amount  of  bone  demanded.  The  soft  structures  are 
freed  on  the  dorsum  of  the  foot  in  the  way  previously 
described ;  but,  as  the  base  of  the  osseous  wedge  for 
equinus  cases  is  at  the  dorsum  and  its  apex  at  the  sole,  the 
parallel  wire  director,  instead  of  the  kite-shaped  varus  one, 
is  used.  The  saw  is  successively  inserted  in  its  grooves, 
and  by  keeping  in  mind  the  idea  of  a  keystone  a  clean 
wedge  of  bone  is  cut  out  from  the  dorsum  to  the  sole  of 
the  foot."  The  wedge  is  extracted,  and  the  foot  is  straight- 
ened and  is  put  in  plaster  or  in  a  Davy  splint. 

Operative  Treatment  of  Recent  Fractures. — In  recent 
fractures  where  reduction  is  impossible  or  where  displace- 
ment recurs  in  spite  of  splints,  it  may  be  advisable  to  oper- 
ate. In  such  cases  a  skiagraph  should  always  be  taken, 
and  it  will  often  decide  whether  operation  is  or  is  not  indi- 
cated. In  most  instances  of  irreducible  fracture  reduction 
of  the  fragments  is  impossible  because  of  muscle  or  fascia 
caught  between  them  or  because  of  hardening  and  shorten- 
ing of  periosteal  soft  parts,  due  to  hemorrhage  and  inflam- 


FiG.  196. —  Bone  ferrules  (Senn). 

mation.  In  such  cases  it  may  be  necessary  to  make  a 
tolerably  long  incision  ;  the  ends  of  the  fragments  are  loos- 
ened from  their  anchorage,  the  inflammatory  ties  are  cut, 
tissue  is  removed  from  between  the  fragments,  and  if  the 
ends  are  very  irregular  they  are  sawn  off  evenly. 

1  Barker's  Manual  of  Surgical  Operations. 


OPERATIVE    TREATMENT  OF  FRACTURES. 


591 


The  fragments  are  bored  and  brought  together,  and  are  held 
by  silver  wire  or  kangaroo-tendon,  or  both  fragments  are  sur- 
rounded by  Senn's  bone  ferrule,  and  fixation  is  thus  secured 
(Figs.  196,  197).     Drainage  is  unnecessary,  the  soft  parts  are 


Fig.  197.— Bone  ring  and  ferrule  applied  (Scnn). 

sutured  and  dressed  with  sterile  gauze,  and  the  extremity  is 
put  up  in  plaster.  If  the  clavicle  is  operated  upon,  after 
sterile  dressings  are  applied  a  Velpeau  bandage  is  put  on. 
and  the  turns  of  this  bandage  are  overlaid  with  plaster-of- 
Paris  a  trap-door  being  cut  over  the  seat  of  operation.  In 
such '  operations  the  author  does  not  use  an  Esmarch  band- 
age as  he  believes  it  best  to  see  what  is  cut  and  thoroughly 
arrest  bleeding  at  the  time,  rather  than  run  the  danger  of 
oozing  and  infection. 

The  author  has  wired  recent  fractures  of  the  humerus, 
tibia  femur,  and  clavicle.  Arbuthnot  Lane  believes  that 
every  very  oblique  fracture  of  the  tibia  and  fibula  low  down 
should  be  treated  by  incision  and  fixation.'  It  is  necessary 
to  bear  in  mind  that  if  one  of  two  parallel  lines  is  broken  (as 
the  radius  alone  or  tibia  alone),  and  it  is  found  necessary  to 
resect  a  considerable  portion,  a  Hke  amount  should  be  re- 
sected from  the  companion  bone  in  order  to  prevent  great 

deformity.  „      , 

Recent  Transverse   Fracture   of  the  Patella  (see  page 

495)- 

1  Brit.    Med.  Jour.,  April  20,  1895. 


Sg2   DISEASES  AND    EVjrA'/ES    OF  JW.VES  AND  JOINTS. 

Bone-grafting,  or  Transplantation  (see  page  398). 
Operative  Treatment  of  Ununited  Fracture. — The 

instruments  required  in  this  operation  are  a  scalpel,  hemo- 
static forceps,  dissecting-forceps,  retractors,  Allis's  dissector. 


Fig.  199. — Brainard's  drills  with  Wyeth's  adjustable  handles. 

an  awl  or  special  drill  (Figs.  198,  199),  chisels,  a  mallet,  a  iine 
saw,  lion-jaw  forceps,  and  silver  wire. 

In  operating,  incise  longitudinally  down  to  the  seat  of 
fracture,  retract  the  periosteum  from  the  bone,  drill  the  bones 
before  cutting  them,  chisel  away  the  material  of  imperfect 
union,  saw  through  each  end  far  enough  from  the  seat  of 
fracture  to  reach  sound  tissue,  pass  large  silver  wires  through 
the  holes  (this  wire  should  be  one-tenth  inch  in  diameter  for 
the  femur,  one-sixteenth  inch  for  the  patella,  etc.)  (Fig.  200),^ 


Fig.  200. — Wiring  of  bones  for  ununited  fracture  :  aa,  sawn  surfaces  approximated  after 
removal  of  old  material  which  was  interposed  between  the  fragments ;  bb,  bb,  perforations 
drilled  completely  across  the  bone  ;  cc,  wires  ready  for  twisting. 


twist  the  wires  a  fixed  number  of  times  (two  complete  turns) 
in  the  direction  that  the  hands  of  a  watch  move  (this  is 
Keen's   direction   in  case   removal  of  the  wires   should  be 


OPERATIVE  TREATMENT  OF  UXUXITED  FRACTCRES.    593 


demanded),  sever  the  ends  of  the  wires,  and  hammer  their 
stems  against  the  bone.  The  wires  may  never  require  re- 
moval. Dress  the  part  as  a  recent  fracture.  Various  plans 
besides  wiring  have  been  employed  in  ununited  fracture. 
Gussenbauer's  clamp  is  used  by  some.  Clayton  Parkhill's 
bone-clamp  is  a  very  useful  appliance,  and  holds  the  frag- 
ments firmly  in  contact  (Fig.  Il6).  Menard  and  Lanne- 
longue  inject  a  i  :  10  solution  of  chlorid  of  zinc  between  the 
fragments  and  around  their  ends,  and  then  immobilize  the 
parts.  Some  surgeons  unite  the  fragments  with  kangaroo- 
tendon  instead  of  wire  (suturing  of  bone) ;  others  use  nails 
of  bone  or  ivory ;  others  use  screws.  Senn  asserts  that  the 
above  methods  wdll  not  hold  fragments  in  contact  if  these 
fragments  have  a  tendency  to  become  displaced.  Senn 
fastens  the  bones  together  by  hollow  cylinders  of  decalcified 
bone  or  ivory,  the  cylinders'being  perforated  in  many  places 
(bone  ferrules)  (Fig.  196).  The  soft  parts  are  sutured,  no 
drain  is  used,  and  the  limb  is  encased  in  plaster. 

Ununited  Fracture  of  Patella.— An  incision  is  made  m 
the  long  axis  of  the  limb,  over  the  middle  of  the  space 
between  the  fragments,  from  well 
above  the  upper  fragment  to  well 
below  the  lower  piece;  this  in- 
cision divides  all  the  soft  parts. 
The  soft  parts  are  retracted, 
but  the  periosteum  is  undis- 
turbed; each  fragment  is  bored 
(Fig.  201,  i)  in  one  or  two 
places ;  the  surfaces  of  the  frag- 
ments are  cut  square  through 
sound  bone  with  a  saw ;  all  old 
reparative  material  is  cut  away; 
the  wires  are  passed  through  the 
perforations,  twisted,  cut  off,  and 
hammered  down  as  before  (Fig. 
201,  2).  If  the  ends  cannot  be 
approximated,  it  may  become  nec- 
essarv  to  incise  the  muscle  around 
and  above  the  patella  or  to  partially  separate  the  tuberosity 
of  the  tibia  and  bend  this  process  upward.  A  small  drain 
is  inserted  above  the  bone,  the  wound  is  sutured,  aseptic 
dressings  are  applied,  and  the  limb  is  put  upon  a  Macewen 
splint. 

Treves' s  Operation  for  Caries  of  the  I,utnbar  and 
I^ast  Dorsal  Vertebrae. — In  this  operation  the  right  loin 
is  chosen  for  incision,  as  a  rule.     The  instruments  required 

3S 


Fig.  201. — Wiring  of  the  patella  :  i, 
fragments  cut  and  cleaned  and  the 
wires  passed  :  2,  wires  twisted  and 
hammered  down  upon  the  bone  (after 
Barker). 


594   DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS. 

are  a  scalpel,  hemostatic  forceps,  grooved  director,  an  Allis 
dissector,  sequestrum-forceps,  curet  spoons,  and  a  sand  bag. 

Operation. — The  patient  lies  upon  his  left  side,  with  the 
knees  drawn  up  and  a  sand  bag  under  him.  The  surgeon 
stands  behind  the  patient  (Barker).  An  incision  is  made  at 
the  outer  border  of  the  erector  spinae  mass,  reaching  from 
the  last  rib  to  the  iliac  crest  and  going  down  at  once  to  the 
lumbar  fascia.  The  lumbar  aponeurosis  is  opened,  the  erector 
spinas  is  retracted  inward,  and  the  anterior  portion  of  the 
erector  spinae  sheath  is  incised.  The  quadratus  lumborum 
muscle  is  next  cut,  and  then  the  anterior  leaflet  of  the  lumbar 
aponeurosis  is  slit.  Loose  pieces  of  bone  are  removed  with 
forceps,  and  cavities  are  thoroughly  curetted.  The  wound 
is  irrigated  with  corrosive  sublimate  and  is  dusted  with  iodo- 
form ;  a  large  tube  is  inserted ;  the  wound  is  packed  with 
iodoform  gauze,  is  partly  closed  by  sutures  of  silkv/orm  gut, 
and  is  dressed  antiseptically. 

Aspiration  of  Joints. — In  certain  cases  of  joint-effusion 
from  inflammation,  tubercular  or  otherwise,  and  sometimes 
in  hemorrhage  into  a  joint,  it  is  desirable  to  remove  the  fluid 
by  aspiration.     The  pneumatic  aspirator  is  used  (Fig.  202). 


Fig.  202. — Aspirator  and  injector. 


The  trocar  and  cannula  are  thoroughly  asepticized  and  the 
joint  is  prepared  as  for  a  set  operation.  The  needle  is  entered 
at  a  surface  free  from  vessels.  The  directions  for  using  an 
aspirator  are  as  follows :  insert  the  stopper  firmly  into  a 
strong  bottle  (a  clear  glass  one  preferred),  then  attach  the 
short  elastic  hose  to  the  stopcock  B  of  the  tube  projecting 
from  the  stopper,  and  attach  the  other  end  of  the  same  elastic 


EXCISIOA'S   OF  BOXES  AND  JOINTS.  595 

hose  to  the  exhausting  or  inward-flowing  chamber  of  the 
pump.  Next  attach  one  end  of  the  longer  elastic  hose  to 
the  stopcock  A  projecting  from  the  stopper,  and  the  other 
end  to  the  needle.  Care  should  be  taken  that  all  the  fittings 
or  attachments  are  placed  firmly  into  their  respective  places. 
Now  close  the  stopcock  A  and  open  stopcock  B,  and  by 
giving  from  thirty-five  to  fifty  strokes  of  the  pump  a  suffi- 
cient vacuum  can  be  produced  to  fill  with  the  fluid  from  the 
joint  a  bottle  holding  from  a  pint  to  a  quart.  After  having 
formed  the  vacuum,  close  the  stopcock  B,  and  the  instru- 
ment is  for  use.  The  trocar  may  be  used  to  inject  antiseptic 
agents  into  the  part.  The  part  is  dressed  antiseptically  and 
is  put  at  rest  upon  splints. 

Bxcisions  of  Bones  and  Joints. — Excision  or  resec- 
tion of  a  joint  is  the  removal  of  the  articular  portions  of  the 
bones  of  the  joint,  and  also  the  cartilage  and  synovial  mem- 
brane. In  the  hip-joint  and  shoulder-joint  the  head  of  the 
long  bone  only  may  be  removed,  and  not  the  articular  sur- 
faces of  both  bones.  In  excision  enough  bone  is  known  to 
have  been  removed  only  when  the  remaining  bone  bleeds. 
Excision  of  a  bone  is  the  removal  of  an  entire  bone  or  of  a 
portion  of  it.  Excision  is  a  conservative  operation  which 
often  averts  amputation. 

Excision  may  be  performed  by  the  open  method,  in  which 
the  periosteum  is  not  preserved,  or  it  may  be  performed  by 
the  subperiosteal  method,  in  which  the  periosteum  is  carefully 
separated  by  a  rugine  and  the  capsular  ligament  is  preserved, 
Artlirectoviy ,  or  evasion,  is  the  excision  of  the  diseased  syno- 
vial membrane  and  ligament,  and  also  small  foci  of  disease 
of  bone  and  cartilage. 

Excision  may  be  employed  for  compound  dislocation,  and 
in  compound  dislocations  of  the  elbow  and  the  shoulder  it  is 
usually  performed.  Excisions  for  compound  dislocations  in 
other  large  joints  are  very  dangerous ;  they  are  rarely  at- 
tempted in  battle-field  practice,  and  are  to  be  avoided  even  in 
civil  practice  unless  the  patient  is  young  and  vigorous  and 
every  advantage  can  be  given  him  during  the  operation  and 
convalescence.  Excision  for  deformit}-  is  rarely  performed 
except  upon  the  hip,  the  knee,  and  the  shoulder,  and  these  ex- 
cisions must  not  be  employed  if  the  patient's  condition  leads 
one  to  fear  the  result  of  a  protracted  convalescence.  Ex- 
cision of  the  elbow,  however,  is  usually  a  safe  operation.  In 
excising  for  deformity  always  consider  the  patient's  trade  and 
the  demands  of  habitual  position  which  it  makes  upon  him.^ 

1  Joseph  Bell,  in  his  Manual  of  Surgical  Operations. 


596  DISEASES  A, YD   IXJURIES   OF  BOXES  AND  JOINTS. 

Excision  is  largely  employed  for  joint-disease,  especially 
for  tubercular  joints.  Bell  states  that  attempts  to  preserve 
the  limb  without  excision  are  more  largely  justifiable  in  the 
lower  than  in  the  upper  limbs,  because  operation  in  the  lower 
extremity  is  more  dangerous  than  in  the  upper,  and  because 
a  cure  without  operation  in  the  lower  limbs,  if  this  cure  can  be 
brought  about,  gives  as  good  a  result  as  a  cure  by  excision. 
In  the  upper  extremities  the  danger  from  operation  is  less 
than  is  the  danger  from  waiting.  In  a  young  subject  an  ex- 
cision may  remove  the  epiphysis,  and  thus  lead  to  permanent 
shortening,  which  is  productive  of  less  inconvenience  and  de- 
formity in  the  arm  than  in  the  leg.  The  great  danger  of  ex- 
cision operations  is  that  the  section  may  be  made  through 
cancellous  bony  tissue  ;  hence  suppuration,  phlebitis,  myelitis, 
septicemia,  or  pyemia  may  follow  ;  further,  in  excision  the  cut 
is  through  diseased  tissue,  and  a  protracted  convalescence  is 
often  inevitable.  Amputation  is  effected  through  healthy 
tissue,  and  the  convalescence  is  short.  Excision,  however, 
when  successful,  gives  the  patient  a  very  useful  limb. 

Brasion,  or  Arthrectomy. — Erasion  is  the  complete  re- 
moval of  diseased  synovial  membrane,  ligaments,  etc.  This 
operation  seeks  to  remove  a  depot  of  infection  in  an  early 
stage  of  tubercular  synovitis,  and  it  possesses  the  conspicu- 
ous merit  of  not  interfering  with  the  epiphysis.  Erasion  is 
oftenest  practised  upon  the  knee-joint.  The  instruments 
required  are  a  scalpel,  hemostatic  forceps,  dissecting-forceps, 
toothed  forceps,  volsellum,  scissors,  bone-gouges,  curets,  and 
an  Esmarch  apparatus. 

Erasion  of  the  Kjzee-Joint. — The  patient  lies  upon  his  back ; 
the  limb  is  flexed  with  the  sole  of  the  foot  planted  upon  the 
table,  and  an  Esmarch  bandage  is  applied  at  a  point  well  up 
on  the  thigh.  The  surgeon  stands  to  the  right  of  the  patient. 
The  incision  starts  in  the  mid-line  of  the  thigh  (on  the  side 
opposite  to  that  occupied  by  the  surgeon),  about  three  inches 
above  the  patella ;  it  is  carried  down  across  the  ligament  of 
the  patella  and  up  to  a  corresponding  point  on  the  opposite 
side  of  the  thigh.  This  incision  is  made  down  to  the  bone ; 
the  flap  is  turned  up  and  the  joint  exposed  ;  the  knee-joint  is 
strongly  flexed,  and  the  synovial  membrane  and  diseased 
ligaments  are  dissected  away  with  scissors  and  forceps,  great 
care  being  taken  that  the  posterior  ligaments  (which,  fortu- 
nately, are  rarely  implicated  early  in  the  case)  are  not  divided 
and  that  the  contents  0/  the  popliteal  space  remain  intact. 
After  removing  the  diseased  ligaments  and  synovial  mem- 
brane examine  the  cartilage  and  remove  any  diseased  por- 


ERASION,    OR    ARTIIRECTOMY. 


597 


tion,  and  then  examine  the  bone  and  gouge  away  any  tuber- 
cular foci.  Ligate  any  exposed  vessels,  irrigate  the  wound 
and  dust  with  iodoform,  straighten  the  extremity,  suture  to- 
gether the  ends  of  the  ligamentum  patellae,  suture  the  skin 
after  inserting  a  drainage-tube  in  each  angle,  dust  iodoform 
over  the  wound,  and  dress  antiseptically.  Put  the  limb  upon 
a  posterior  splint  for  a  few  days,  then  take  out  the  drainage- 
tubes,  re-dress  antiseptically,  and  put  up  in  a  plaster-of- Paris 
cast,  cutting  trap-doors  upon  each  side  and  keeping  the 
joint  immobile  for  two  or  three  weeks.     This  operation  is 


Fig.  20^. 


Fig.  204. 


Fig.  203. — i-io.  Amputations  (Joseph  Bell):  i,  of  lower  third  of  forearm  (Teale's) ; 
2,  at  shoulder-joint  by  large  postero-external  flap  (second  method)  ;  3,  ar  shoulder-joint  by 
triangular  flap  from  deltoid  (third  method)  ;  4,  5,  through  tarsus  (Chopart's):  6,  7,  at  knee- 
joint  ;  8.  by  single  flap  (Garden's) ;  9,  10,  of  thigh  (Teale's).  A,  excision  of  hip  ;  B,  of  ankle- 
joint  (Hancock's  incision). 

Fig.  204.— 1-18,  Amputations  (Joseph  Bell) :  i,  amputation  at  wrist-joint  (dorsal  in- 
cision) ;  2,  at  wrist-joint  (palmar  incision);  3,  at  forearm  (dorsal  incision);  4,  at  forearm 
(palmar  incision  1  ;  5,  at  elbow-joint  (anterior  flap)  ;  6,  at  arm  (Teale's) ;  7,  at  shoulder-joint 
(first  method);  8,  g,  of  metatarsus  (Hey's)  ;  10,  11,  at  ankle  (Syme's)  ;  12,  13,  of  leg,  pos- 
terior flap  (Lee's);  14,  at  knee-joint  (Garden's);  15,  of  thigh  (B.  Bell's);  16,  of  thigh 
(Spence's)  ;  17,  of  thigh  in  middle  third;  18,  at  hip-joint.  A,  excision  of  wrist  (radial  in- 
cision) ;  B,  of  wrist  (ulnar  incision). 

only  suited  to  early  cases  in  which  the  lesion  involves  chiefly 
or  purely  the  synovial  membrane  and  ligaments,  and  in  these 
cases  it  frequently  gives  a  good  result,  some  capacity  for 
motion  being  not  unusually  preserved. 

Excision  of  the  Shoulder-joint. — In   the   shoulder-joint 


598   DISEASES  AND   INJUJilES   OF  BOAES  AND  JOINTS. 


partial  excision  is  often  performed,  the  head  of  the  humerus 
being  removed  and  the  glenoid  being  undisturbed ;  but  some 
patients  require  complete  excision,  the  entire  glenoid  depres- 
sion, as  well  as  the  head  of  the  humerus,  being  removed  by 
the  surgeon.  Excision  of  the  shoulder-joint  is  made,  if 
possible,    an    intracapsular   operation,    the    capsule    being 

Fig.  205.  Fig.  206. 


Fig.  205. — 1-9,  Amputations  (Joseph  Bell)  :  i,  of  arm  by  double  flaps  ;  2,  at  shoulder- 
joint  ;  3,  at  ankle-joint  by  internal  flap  (Mackenzie's)  ;  4,  5,  of  leg  just  above  the  ankle-joint 
(Syme's)  :  6,  7,  below  the  knee  (modified  circular) :  S,  through  condyles  of  femur  (Syme's) ; 
9,  at  lower  third  of  thigh  (Syme's).  A,  excision  of  head  of  humerus ;  b,  of  knee-joint  (serai- 
lunar  incision). 

Fig.  206. — 1-8,  Amputations  (Joseph  Bell)  :  i,  at  elbow-joint  (posterior  flap)  ;  2,  at  shoul- 
der-joint, posterior  incision  (first  method)  ;  3,  at  ankle-joint  (Mackenzie's)  ;  4,  through  con- 
dyles of  femur  (Syme's) ;  5,  at  lower  third  of  thigh  (Syme's)  ;  6,  at  knee  (posterior  incision) ; 
7,  of  thigh  (Spencer's);  8,  at  hip-joint,  a-g,  Excisions;  a,  excision  of  shoulder-joint  (deltoid 
flap)  ;  B,  of  shoulder-joint  (posterior  incision)  ;  c,  of  elbow-joint  (H-shaped  incision)  ;  d,  of 
elbow-joint  (linear  incision)  ;  E,  of  hip-joint  (Gross's) ;  F,  of  os  calcis  ;  G,  of  scapula. 

opened,  but  the  capsular  attachment  to  the  anatomical 
neck  not  being  interfered  with.  In  bad  cases,  however,  the 
capsular  attachment  must  be  destroyed.  This  operation  is 
rare  in  civil,  but  is  common  in  military  practice ;  it  is  per- 
formed in  gunshot-wounds,  in  compound  dislocations,  in 
tubercular  disease,  and  in  tumors  of  the  head  and  upper  por- 
tion of  the  humerus.  The  instruments  required  are  a  scalpel, 
an  Adams  saw,  an  osteotome  or  chisel,  a  mallet,  an  Allis 
dissector,  a  periosteum-elevator,  hemostatic  forceps,  dissect- 
ing-forceps,  toothed  forceps,  lion-jawed  forceps,  sequestrum- 
forceps,  metal  retractors,   curets,  and  cutting  bone-forceps. 


EXCIS/OX  OF  THE  SHOULDER-JOINT.  599 

Operation  by  A)itcrior  Incision. — The  patient  lies  supine ; 
a  pillow  is  placed  beneath  the  shoulders,  and  a  sand  pillow 
is  put  beneath  the  shoulder  to  be  operated  upon.  The  arm 
is  held  to  the  side  with  the  outer  condyle  forward  and  the 
bicipital  groove  inward  (Barker's  directions).  The  surgeon 
stands  by  the  affected  side.  An  incision  three  or  four 
inches  in  length  is  made  from  just  external  to  the  cora- 
coid  process,  running  straight  down  the  humerus  (Fig. 
205,  a).  This  incision  divides  the  border  of  the  deltoid 
muscle  and  brings  into  sight  the  long  head  of  the  biceps. 
The  tendon  of  the  biceps  is  retracted  inward,  unless  it  is  dis- 
eased, in  which  case  it  is  resected.  The  knife  is  carried  up 
the  groove  and  opens  the  capsule  of  the  joint.  The  peri- 
osteum is  lifted  from  the  neck  of  the  bone  while  an  assistant 
rotates  the  elbow  to  make  the  muscles  tense.  In  some 
places,  if  the  periosteum  tears,  muscular  insertions  must  be 
cut  with  a  knife.  The  head  of  the  bone  is  sawn  off  while 
the  bone  is  in  place,  or  the  elbow  is  strongly  pulled  back,  and 
the  head  of  the  bone  is  forced  out  of  the  wound,  and  is  then 
sawn  off  at  the  point  required.  In  ordinary  cases  remove 
only  the  articular  head;  in  other  cases  make  the  section  just 
above  the  surgical  neck ;  in  yet  others  remove  a  portion  of 
the  shaft.  If  the  glenoid  cavity  is  found  slightly  diseased, 
any  dead  bone  must  be  removed  by  the  chisel  and  mallet 
or  by  the  cutting-forceps.  If  the  cavity  is  seriously  diseased, 
the  entire  glenoid  should  be  removed.  Scrape  aAvay  all  dam- 
aged tissue  ;  ligate  bleeding  points  ;  irrigate  the  wound  with 
corrosive-sublimate  solution  ;  swab  it  out  with  a  solution  of 
chlorid  of  zinc  (gr.  xx  to  Sj) ;  dust  with  iodoform ;  close 
the  upper  portion  of  the  wound  and  insert  a  drainage-tube 
in  the  lower  angle ;  dress  the  wound  antiseptically ;  place 
a  small  pad  in  the  axilla;  apply  the  second  roller  of 
Desault;  and  put  the  patient  in  bed  with  a  pillow  under 
the  affected  shoulder.  In  seven  days  the  hand-sling  is 
substituted  for  the  bandage,  and  with  the  elbow  hanging 
free  the  patient  is  permitted  to  get  up  and  is  advised  to 
move  his  arm  frequently.  Drainage  is  maintained  until 
the  wound  is  well  healed  from  the  bottom.  Great  limi- 
tation of  movement  inevitably  follows  upon  a  shoulder-joint 
resection. 

Excision  by  the  deltoid  flap  is  performed  w^hen  the  head 
of  the  bone  is  much  enlarged  (as  by  a  tumor)  or  when  the 
tissues  are  thick  and  indurated.  The  deltoid  flap  is  in 
the  shape  of  a  V  or  is  semilunar  (Fig.  206,  a).  Raising  this 
flap  exposes  the  head  of  the  bone  most  satisfactorily.     Bell 


600   DISEASES  AND   IXJURIES   OE  BOAES  AND  JOINTS. 

states  that  when  the  glenoid  cavity  is  chiefly  involved  the 
incision  should  be  posterior  (Fig.  206,  b). 

Se7in's  Method. — Senn  has  recently  described^  an  incision 
which  does  not  damage  any  important  vessels,  muscles,  ten- 
dons, or  nerves,  and  which  is  followed  by  good  functional 
results.  A  semilunar  skin-flap  is  formed,  the  incision  run- 
ning from  the  coracoid  process  to  the  posterior  border  of  the 
axillary  space.  This  flap  is  turned  up,  exposing  the  upper 
half  of  the  deltoid  muscle.  The  acromion  is  sawn  off  and 
turned  down  with  the  attached  deltoid.  The  capsule  is  now 
freely  exposed  ;  it  is  opened,  and  either  arthrectomy  or  excis- 
ion is  performed,  according  to  conditions.  In  closing  the 
wound  it  is  not  necessary  to  bore  the  acromion  and  pass 
silver  wires  to  join  the  fragments ;  it  is  enough  to  suture  the 
periosteum  with  catgut. 

Excision  of  the  Elbow-joint. — This  operation  is  per- 
formed for  wounds,  faulty  ankylosis,  and  chronic  articular 
disease.  Excision  must  be  complete.  Endeavor  to  make 
a  subperiosteal  resection ;  this  maintains  the  shape  of  the 
articulation  and  gives  the  best  chance  for  a  movable  joint. 
The  instruments  used  are  the  same  as  those  for  the  shoulder, 
plus  a  Butcher  saw. 

Operation. — The  patient  is  "  supine,  but  inclining  to  the 
sound  side,  the  afiected  arm  being  held  almost  vertical,  with 
the  forearm  flexed  and  nearly  horizontal"  (Barker).  The 
incision  is  made  on  the  posterior  surface  of  the  joint.  A 
single  posterior  incision  is  usually  employed  (Fig.  206,  d,  f). 
An  incision  is  made  a  little  internal  to  the  long  axis  of  the 
olecranon,  and  reaching  two  inches  above  and  two  inches 
below  the  tip  of  the  olecranon.  This  incision  goes  down  to 
the  bone,  and  throughout  the  entire  operation  the  surgeon 
must  guard  and  shield  the  ulnar  nerve.  The  periosteum 
and  soft  parts  are  well  separated ;  the  olecranon  is  sawn  off; 
forced  flexion  exposes  the  joint-cavity  freely,  and  enables 
the  surgeon  to  lift  the  periosteum  and  soft  parts  from  the 
humerus  ;  the  humerus  is  sawn  through  at  the  beginning 
of  its  condyloid  processes ;  the  radius  and  ulna  are  cleared 
and  are  sawn  at  a  level  below  that  of  the  base  of  the  coro- 
noid  process  of  the  ulna.  Cut  and  spoon  away  diseased 
tissues,  the  wound  being  irrigated,  closed,  drained,  and  dressed. 
In  some  cases  an  H-shaped  incision  is  employed  (Fig.  206,  c), 
but  the  cicatrix  of  a  transverse  cut  will  limit  flexion  of  the 
limb. 

After  excision  of  the  elbow  the  patient  is  put  to  bed  and 

1  Phila.  Med.  Joiirn.,  Jan.  i,  1898. 


EXCISIOX  OF   THE   ELBOW-JO  I  XT. 


60 1 


the  arm  is  laid  upon  a  pillow,  the  elbow  being  placed  mid- 
way between  a  right  angle  and  complete  extension,  the  fore- 
arm being  placed  midway  between  pronation  and  supination. 
No  splint  is  used,  as  a  rule.  Esmarch  used  the  splint  shown 
in  Figure  207.  The  aim  in  treatment  is  to  obtain  a  freely 
movable  joint.  Passive  motion  is  begun  in  one  week,  when 
the  patient  gets  up.    The  hand  is  carried  for  a  time  in  a  sling. 


Fig.  207. — Esmarch's  splint  for  the  treatment  of  a  limb  a'ur  i-xci'^i  in  of  the  elbow  lomt 

Excision  of  the  "Wrist-joint. — Bell  states  that,  whatever 
method  of  excision  is  chosen,  three  cardinal  rules  must  be 
borne  in  mind:  (i)  remove  all  the  diseased  bone,  including 
the  portions  of  the  radius,  ulna,  carpus,  and  metacarpus  which 
are  covered  with  cartilage  ;  (2)  interfere  with  the  tendons  to 
the  least  possible  degree  ;  and  (3)  begin  passive  motion  of 
the  fingers  ver}'  early.  Many  surgeons  prefer  the  simple 
gouging  away  of  diseased  foci  and  the  scraping  of  sinuses 
instead  of  a  formal  resection  of  the  wrist,  amputation  being 
employed  in  severe  cases  or  when  scraping  fails  after  several 
trials.  Formal  excision  is  not  very  often  done,  and  the 
results  cannot  often  be  considered  as  ver}'  favorable. 

Lister  s  Open  Metliod  of  Excision. — The  instruments  re- 
quired in  this  operation  are  the  same  as  those  used  for  any 
resection.  Break  up  adhesions  as  completely  as  possible  by 
forcible  movements.  Apply  a  tourniquet  or  an  Esmarch  appa- 
ratus. The  patient  lies  upon  his  back,  the  arm  and  the  fore- 
arm being  brought,  from  stao-e  to  stare,  into  the  most  desirable 
positions.  Begin  an  incision  over  the  middle  of  the  dorsum 
of  the  radius,  on  a  level  with  the  styloid  process ;  carry  it 
downward  in  the  direction  of  the  inner  edge  of  the  articula- 
tion of  the  thumb  with  its  metacarpal  bone,  and  when  the 
knife  reaches  the  radial  side  of  the  second  metacarpal  bone 
alter  the  direction  of  the  incision  and  earn,'  it  downward  in 
the  long  axis  of  the  metacarpal  bone  to  about  its  middle 
(Fig.  204,  a).     This  is  known  as  the  radial  incision,  and  the 


6o2   DISEASES  AND    IXJURIES   OF  BO. YES  AND  JOINTS. 

only  tendon  divided  is  that  of  the  extensor  carpi  radiahs 
brevier  muscle.  The  tissues  upon  the  radial  aspect  of  the 
incision  are  dissected  up,  the  tendon  of  the  extensor  carpi 
radialis  longior  muscle  is  divided  at  its  point  of  insertion 
(Bell),  and  all  the  soft  structures  are  retracted  outward, 
exposing  the  trapezium,  which  is  cut  off  from  the  rest  of  the 
carpus,  but  which  is  left  in  place,  as  its  removal  at  this  stage 
endangers  the  radial  artery  (Barker).  By  extending  the 
hand  the  tendons  are  loosened  and  the  carpus  is  cleared  in 
the  direction  of  the  ulnar  border  of  the  hand. 

Another  incision  is  made,  starting  upon  the  inner  surface 
of  the  wrist,  two  inches  above  the  articular  surface  of  the 
ulna,  and  midway  betw^een  the  ulna  and  the  flexor  carpi 
ulnaris  tendon.  This  incision,  which  is  known  as  the  ulnar 
incision,  is  carried  down  until  it  is  opposite  the  middle  of 
the  fifth  metacarpal  bone  in  the  palm  (Fig.  204,  b).  "The 
dorsal  lip  of  this  incision  is  raised  "  (Bell),  and  the  extensor 
carpi  ulnaris  tendon  is  divided  and  dissected  from  its  depres- 
sion, but  is  not  separated  from  the  integument.  The  extensor 
tendons  are  lifted ;  the  ligaments  upon  the  dorsum  and 
sides  of  the  wrist-joint  are  cut ;  the  flexor  tendons  are  raised 
from  the  carpal  bones ;  the  pisiform  bone  is  cut  from  the 
carpus,  but  is  not  yet  removed ;  and  the  unciform  process  of 
the  unciform  bone  is  cut  with  forceps.  The  anterior  radio- 
carpal ligament  is  divided,  the  carpometacarpal  articulations 
are  cut  through,  and  the  carpus  is  pulled  out  with  bone- 
forceps.  The  ends  of  the  radius  and  ulna  are  forced  out  of 
the  ulnar  incision.  All  that  portion  of  the  ulna  which  is 
crusted  with  cartilage  is  to  be  removed,  the  saw-cut  is  to  be 
oblique,  and  the  base  of  the  styloid  process  is  to  be  left 
behind.  A  thin  section  is  to  be  sawn  from  the  radius,  and 
the  tendon-grooves  are  not  to  be  impinged  upon.  The  artic- 
ular surface  of  the  ulna  is  cut  away  with  pliers  (Bell).  If 
foci  of  disease  are  discovered  beyond  these  points,  they  are 
to  be  goug'ed  out.  The  ends  of  the  metacarpal  bones  are 
sawn  ofl",  and  their  articular  facets  are  cut  away  by  means 
of  pliers.  The  trapezium  is  dissected  out,  the  end  of  the 
first  metacarpal  bone  is  sawn  off  and  its  facet  is  cut  away 
with  pliers,  and  a  portion  of  the  pisiform  bone  is  removed 
(the  entire  bone  being  removed  if  it  be  diseased).  The 
wound  is  irrigated,  vessels  are  tied,  the  radial  incision  is 
closed,  the  ulnar  incision  is  partly  closed,  a  drainage-tube 
is  inserted  by  way  of  the  ulnar  incision,  the  wounds  are 
dressed  antiseptically,  and  the  Esmarch  apparatus  is  taken 
ofl!     The  forearm  and  hand  are  placed  upon  a  splint  which 


EXCISION  OF   THE    HIP-JOINT. 


603 


immobilizes  the  wrist  and  leaves  the  fingers  semiflexed.  The 
splint  is  worn  for  many  months,  until  the  wrist-joint  is  immo- 
bile and  solid.     Esmarch  uses  the  splint  shown  in  Fig.  208. 


Fig.   208.— Esmarch's  interrupted  splint  applied. 


Passive  motion  of  the  fingers  is  begun  after  thirty-six 
hours. 

Excision  of  Metacarpal  Bones  and  of  Phalanges. — 
Excision  of  a  metacarpal  bone,  except  in  cases  of  necro- 
sis with  the  formation  of  large  quantities  of  new  bone, 
usually  leaves  a  useless  finger ;  hence  amputation  is  pre- 
ferred usually  to  excision.  This  rule  does  not  apply  to 
the  metacarpal  bone  of  the  thumb,  which  is  occasionally 
resected.  The  incision  for  this  operation  is  made  upon  the 
dorsum,  and  is  straight.  Excision  of  the  proximal  phalanx 
of  the  thumb  is  sometimes  performed.  Excision  for  disease 
is  rarely  performed  upon  the  finger-joints,  amputation  being 
preferred,  though  the  operation  is  sometimes  undertaken  for 
compound  dislocation.  In  the  metacarpophalangeal  joint 
of  the  thumb  excision,  if  it  can  be  performed,  is  preferred 
to  amputation.  The  incision  for  resection  of  this  joint  is 
placed  upon  the  radial  aspect. 

Excision  of  the  Hip-joint. — Some  surgeons  advocate  this 
operation  ;  others,  notably  Marsh,  are  emphatically  opposed 
to  it.  Excision  should  be  performed  in  the  early  stage  of 
tubercular  disease  if  less  radical  treatment  lias  failed,  and  in 
this  stage  the  usual  position  of  the  limb  is  one  of  flexion, 
abduction,  and  eversion.  In  cases  of  long  duration,  espec- 
ially where  dislocation  exists,  excision  is  an  easy  and  a  com- 
paratively safe  operation  ;  in  recent  cases  it  is  difficult  and 
carries  with  it  decided  dangers,  but  the  peril  of  delay  may 
be  greater  than  the  peril  of  an  early  resection.  In  cases  of 
hip  disease  with  involvement  of  the  acetabulum  the  mor- 
tality is  50  per  cent.,  whether  operation  is  or  is  not  at- 
tempted.    Excision    is   performed   especially  for  tubercular 


604   DISEASES  AND    INJURIES    OF  BONES  AND  JOINTS. 


disease  and  for  gunshot-injuries.     The  instruments  required 
are  those  used  for  other  excisions. 

Operation  by  Anterior  Incision 
(Fig.  209)  (Parker's  Operation). 
— In  this  operation  the  patient  is 
supine,  with  the  thighs  extended 
as  thoroughly  as  circumstances 
permit.  The  surgeon  stands  to 
the  right  of  the  patient.  An 
incision  is  begun  half  an  inch 
below  and  half  an  inch  external 
to  the  anterior  superior  iliac 
spine,  and  it  is  carried  down- 
ward and  a  little  inward  for 
about  three  inches  (Fig.  209,  d). 
If  dislocation  exists,  the  incision 
must  not  be  so  long.  This  in- 
cision is  carried  at  once  deeply 
between  the  muscles,  and  the 
capsule  of  the  joint  is  opened. 
The  neck  of  the  bone  is  divided 
from  its  upper  surface  down- 
ward with  a  saw  or  an  osteotome, 
and  without  dislocating  the 
bone  through  the  wound  by  forcible  extension  and  eversion, 
the  head  of  the  bone  is  removed.  All  tubercular  foci  must 
be  scraped  away,  and  the  flushing  gouge  is  used  upon  tuber- 
cular areas  of  the  acetabulum.  All  sinuses  should  be  thor- 
oughly scraped.  Bleeding  is  arrested,  the  wound  is  irrigated 
with  corrosive-sublimate  solution,  mopped  out  with  chlorid- 
of-zinc  solution,  and  dusted  with  iodoform.  A  drainage-tube 
is  inserted  at  the  lower  angle  of  the  incision,  and  the  upper 
portion  of  the  cut  is  closed.  The  wound  is  dressed  antisep- 
tically.  Extension  is  made  with  the  extension  apparatus  until 
healing  has  obtained  a  good  headway,  when  a  double  Thomas's 
splint  is  applied,  so  that  the  patient  can  be  taken  out  daily  in 
the  air  and  sunlight.  As  a  rule,  rigid  ankylosis  results  from 
resection  of  the  hip,  but  occasionally  a  joint  results  with  a 
small  range  of  movement. 

Operation  by  Lateral  Incision  (Langenbeck's  Operation). — 
In  this  operation  a  straight  incision  two  inches  long  is  made 
in  the  direction  of  the  axis  of  the  femur,  and  runs  downward 
from  the  apex  of  the  great  trochanter.  From  the  beginning 
of  this  incision  a  curved  incision  is  carried  toward  the  head 
of  the  bone,  the   convexity  of  the   curve  being  backward 


Fig.  209. — Excision  of  the  hip-joint : 
A,  gluteus  muscle;  b,  tensor  vaginae 
femoris  muscle;  c,  sartorius  muscle; 
D,  anterior  incision. 


EXC/SIO.V  OF  THE   KXEE-JOINT.  605 

(Fig.  203,  a).  Bell  advises  the  use  of  the  saw  after  bringing 
the  head  of  the  bone  into  the  wound  by  abduction  and  ever- 
sion  of  the  thigh.  Barker  applies  the  saw  with  the  bone  in 
situ,  and  strongly  opposes  wrenching  the  bone  out  of  the 
incision,  because  of  the  danger  of  peeling  off  the  periosteum, 
which  peeling,  if  it  takes  place,  favors  necrosis. 

Incision  of  Gi'oss. — In  Gross's  operation  a  semilunar  flap 
is  made  with  the  convexity  backward  (Fig.  206,  e). 

Excision  of  the  Knee-joint. — In  this  operation  a  com- 
plete excision  should  be  performed,  and  the  patella  ought  to 
be  removed.  This  operation  is  performed  in  tubercular  dis- 
ease, in  some  compound  fractures  and  compound  disloca- 
tions, and  in  some  cases  of  angular  ankylosis,  but  it  is  rarely 
employed  for  gunshot-injuries,  amputation  being  advisable 
(Ashhurst).  The  instruments  required  are  the  same  as  those 
for  the  shoulder,  plus  Butcher's  saw. 

Operation  by  Anterior  Semilunar  Flap. — The  patient  lies 
upon  his  back,  and  the  joint,  if  not  ankylosed  in  extension, 
is  semiflexed.  The  surgeon  stands  to  the  right  side.  An 
incision  is  made,  at  once  opening  the  joint,  starting  from  one 
condyle  and  reaching  the  other  condyle  by  a  downward 
curve  which  passes  through  the  ligamentum  patellae  midway 
between  the  tuberosity  of  the  tibia  and  the  inferior  margin 
of  the  patella  (Fig.  205,  b).  The  flap  is  dissected  up,  the 
knee  is  thrown  into  forced  flexion,  the  lateral  ligaments  and 
crucial  ligaments  are  cut,  and  the  end  of  the  femur  is  well 
cleared.  The  blade  of  Butcher's  saw  is  passed  beneath  the 
bone,  which  is  sawn  from  below  upward  (Ashhurst).  The 
end  of  the  tibia  is  cleared  and  a  portion  is  sawn  off!  If,  after 
sawing,  diseased  foci  are  discovered,  another  section  can  be 
sawn  off  or  the  foci  can  be  gouged  away.  Ashhurst,  who  has 
had  a  vast  experience  with  this  operation,  insists  that  in  sawing 
through  the  femur  the  natural  obliquity  of  the  bone  must  be 
borne  in  mind  and  the  section  must  be  made  in  "  a  line  parallel 
to  that  of  the  free  surface  of  the  condyles."  If  the  section  is 
made  transverse  to  the  axis  of  the  femur,  "  the  Hmb,  after  ad- 
justment, will  be  found  to  be  markedly  bowed  outward."  The 
same  surgeon  says  that  the  epiphyseal  line  is  somewhat  higher 
on  the  front  than  it  is  on  the  back  of  the  femur,  and  in  con- 
sequence the  following  rule  is  formulated  for  section  of  the 
condyles  :  the  section  of  the  condyles  should  be  "  in  a  plane 
which,  as  regards  the  axis  of  the  femur,  is  oblique  from  be- 
hind forward,  from  beloAv  upward,  and  from  within  outward." 
Ashhurst  advocates  section  of  the  tibia  "  in  a  plane  trans- 
verse to  the  long  axis  of  the  bone,  with  a  slight  anteroposte- 


6o6   DISEASES  AND   EYJ CRIES    OE  BO.XES  AND  j  OINTS. 

rior  obliquity,  so  as  to  correspond  with  that  of  the  section  of 
the  condyles,"  and  further  says  also  that  the  patella  must  be 
removed,  whether  it  is  diseased  or  not,  and  he  quotes  Peniere's 
observations  to  the  effect  that  excision  of  the  patella  dimin- 
ishes the  risk  of  death  one-third,  and  its  retention  doubles  the 
probability  of  an  amputation  becoming  necessar>'in  the  future. 
After  removing  the  patella  the  diseased  synovial  membrane 
is  clipped  away  with  scissors  and  all  sinuses  and  diseased 
territories  are  well  curetted.  The  posterior  ligament  of  the 
joint  is  not  removed  unless  it  is  diseased ;  its  retention  pre- 
vents displacement  and  guards  the  popliteal  space.  In  chil- 
dren the  fragments  should  be  wired  together ;  in  adults  this 
need  not  be  done.  After  hemostasis  irrigate,  dust  with  iodo- 
form, insert  a  drainage-tube,  suture,  dress  antiseptically,  and 
adjust  the  limb  upon  Price's  splint  or  Ashhurst's  bracketed 
wire  splint.  In  some  cases  tenotomy  is  required  to  permit 
extension.  Instead  of  the  bracketed  splint,  a  long  fracture-box 
may  be  used.  If  the  femur  tends  to  project  anteriorly,  use  an 
anterior  splint.  If  there  be  a  tendency  to  outw^ard  bowing, 
adopt  Ashhurst's  expedient  of  carrying  a  strip  of  adhesive 
plaster  around  the  outside  of  the  limb  and  fastening  it  to  the 
inner  side  of  the  splint.  The  splint  is  kept  on  until  bony 
union  is  complete,  as  in  this  operation  a  movable  joint  is 
never  sought.  Many  surgeons  use  a  plaster-of-Paris  splint, 
which  is  employed  until  the  parts  have  become  firm  and  solid 
(Fig.  210). 


Fig.  2IO. — Watson's  plaster-of-Paris  swing-splint. 

Excision  of  the  Ankle-joint. — This  operation  is  per- 
formed chiefly  in  gunshot-wounds,  in  compound  dislocations, 
and  in  early  cases  of  chronic  joint-disease.  Complete  resec- 
tion is  employed  for  chronic  joint-disease.  Excision  of  the 
ankle  is  a  rare  operation.  The  instruments  used  are  the 
same  as  those  employed  for  any  resection. 


liXC/S/OJV   OF   THE   ANKLE-J0IN7\ 


607 


Opcratio)i  (Hancock's  Method). — In  this  operation  the  pa- 
tient Hes  upon  his  back,  the  foot  rests  upon  its  inner  side, 
and  the  surgeon  stands  to  the  outer  side  of  the  damaged  Hmb. 
Begin  an  incision  just  behind  and  twd  inches  above  the  ex- 
ternal malleolus,  and  carry  it  across  the  front  of  the  joint  to  a 
corresponding  point  above  and  behind  the  internal  malleolus 
(Fig.  203,  b);  this  incision  goes  only  through  the  skin,  and 
the  flap  thus  marked  out  is  reflected.  "  Cut  down  upon  the 
external  malleolus,  carrying  the  knife  close  to  the  edge  of  the 
bone  both  behind  and  below  the  process,  dislodge  the  peronei 
tendons,  and  divide  the  external  lateral  ligaments  "  (Joseph 
Bell).  Cut  the  fibula  one  inch  above  the  malleolus  by  means 
of  pliers ;  divide  the  tibiofibular  ligament ;  turn  the  foot  upon 
its  outer  side ;  dissect  from  their  habitat  back  of  the  inner 
malleolus  the  tendons  of  the  posterior  tibial  and  the  com- 
mon flexor  of  the  toes  ;  carry  the  knife  around  the  inner 
malleolus,  close  to  the  bony  edge ;  separate  the  internal  lat- 
eral ligament,  and  dislocate  the  lower  end  of  the  tibia  through 
the  wound  by  turning  the  sole  of  the  foot  downward  ;  saw  off 
the  lower  end  of  the  tibia  and  the  articular  process  of  the 
astragalus,  sawing  away  from  the  tendo  Achillis,  and  remove 
the  fragments  with  bone-forceps.  Cut  away  diseased  syno- 
vial membrane,  and  curet  all  sinuses  and  tubercular  areas. 
Arrest  bleeding,  irrigate,  and  drain.  Sew  up  the  wound, 
insert  a  tube  at  the  outer  angle,  and  cause  it  to  emerge  at  the 
inner  angle.  Apply  antiseptic  dressings,  and  put  up  the  foot 
in  fixed  dressing  or  in  splints  at  a  right  angle  to  the  leg  (Fig. 
211).     In  Langenbeck's  operation  the  excision  is  subperios- 


FiG.  211.— Volkmann's  dorsal  splint  for  excision  of  the  ankle. 

teal.     If,  in  an  excision  of  the  ankle-joint,  the  astragalus  is 
found  extensively  diseased,  remove  the  entire  bone. 

Excision  of  the  Os  Calcis. — In  caries  limited  to  the  os 


6o8    DISEASES  AXD   LXJCRIES    OF  BONES  AND  JOINTS. 

calcis  most  surgeons  prefer  to  gouge  away  the  dead  bone, 
leaving  the  periosteum  and,  if  possible,  a  shell  of  healthy- 
bone,  and  draining  thoroughly.  Others  advocate  excision 
in  some  cases.  Extensive  disease  limited  purely  to  the  os 
calcis  is  rare,  and  most  surgeons  advise  gouging  for  limited 
caries,  and  Syme's  amputation  in  the  event  of  the  disease  ex- 
tending beyond  the  periosteum  or  reaching  adjacent  bones. 

Operation  by  Subperiosteal  Metliod. — In  this  operation  the 
position  assumed  by  the  patient  is  supine  with  the  leg 
extended  and  the  foot  resting  on  its  inner  side.  The 
incision,  which  cuts  the  tendo  Achillis  and  reaches  the 
bone  at  once,  is  begun  at  the  upper  border  of  the  os  calcis 
and  the  inner  margin  of  the  tendo  Achillis,  and  is  taken 
outward  and  horizontally  forward  to  a  point  in  front  of*  the 
calcaneocuboid  articulation.  A  vertical  incision  is  begun 
near  the  forward  termination  of  the  initial  incision,  is  carried 
across  the  outer  edge  and  plantar  surface  of  the  foot,  and 
terminates  at  the  external  margin  of  the  inner  surface  of  the 
OS  calcis.  Some  surgeons  carry  the  vertical  incision  a  little 
upward,  toward  the  dorsum  (Fig.  206,  f).  The  periosteum 
is  entirely  stripped  with  an  elevator,  the  os  calcis  is  removed, 
the  cavity  is  packed  with  iodoformi  gauze,  the  wound  is 
stitched,  a  drain  is  inserted  posteriorly,  and  the  foot  is 
dressed  antiseptically  and  put  up  in  plaster  at  a  right  angle 
to  the  leg,  trap-doors  being  cut  for  drainage. 

Excision  of  the  astragalus  is  a  rare  operation. 

Operation  by  the  Subperiosteal  Plan. — Barker  advises  an 
incision  going  at  once  to  the  bone,  from  the  "  tip  of  the  ex- 
ternal malleolus  forward  and  a  little  inward,  curving  toward 
the  dorsum  of  the  foot."  The  foot  is  extended  and  turned 
inward,  the  periosteum  is  lifted,  the  bone  is  removed,  and 
the  wound  is  treated  and  the  foot  is  dressed  as  is  done  in 
excision  of  the  os  calcis. 

Excision  of  the  Metatarsophalang-eal  Articulation  of 
the  Great  Toe. — In  this  operation  make  a  lateral  incision 
and  cut  off  or  saw  off  the  proximal  end  of  the  first  phalanx 
and  the  distal  third  of  the  first  metatarsal  bone. 

Excision  of  the  Metatarsal  Bone  of  the  Great  Toe 
(Butcher's  Method). — In  this  operation  a  lateral  straight 
incision  is  made,  the  periosteum  is  elevated,  and  the  shaft  is 
sawn  from  each  extremity  and  removed. 

Excision  of  the  clavicle  may  be  required  in  dislocation, 
in  caries,  in  necrosis,  for  gunshot-wounds,  in  tumor  of  this 
bone,  as  a  preliminary  to  ligation  of  the  artery  and  vein  in 
certain  cases  of  amputation  at  the  shoulder-joint,  or  in  cases 


EXCISIOX  OF  A    AVB.  609 

of  removal  of  the  entire  upper  extremity.  In  excision  of 
the  clavicle  the  position  of  the  patient  is  the  same  as  that 
for  ligation  of  the  third  part  of  the  subclavian  artery  (page 
366).  An  incision  is  made  down  to  the  bone,  from  the 
sternoclavicular  joint  to  the  acromiocla\icular  articulation. 
If  the  case  is  suitable,  the  periosteum  is  stripped  and  the 
bone  is  sawn  and  removed ;  if  not,  the  bone  is  sawn  and 
each  half  is  separately  disarticulated.  The  wound  is  sutured 
and  dressed,  and  the  limb  is  put  up  in  a  Velpeau  bandage. 

Excision  of  the  Scapula. — Complete  excision  of  the  scap- 
ula is  most  usual!}'  performed  for  tumors.  Partial  excision 
requires  no  detailed  description.  In  excision  of  the  scap- 
ula the  patient  lies  upon  his  sound  side.  Treves  suggests 
the  following  incisions :  one  outside  the  vertebral  border 
of  the  scapula,  from  its  superior  to  its  inferior  angle ; 
another  from  over  the  acromioclavicular  joint,  along  the 
acromion  process  and  spine  of  the  scapula,  to  meet  the 
first  incision.  Syme  used  an  incision  carried  transversely 
inward  from  the  acromion  process  to  the  vertebral  border 
of  the  scapula,  and  another  cut  directly  downward  from 
the  center  of  the  first  incision  (Fig.  206,  g).  In  the 
method  of  Tre\'es  ^  the  upper  flap  is  reflected  and  the 
trapezius  muscle  is  divided ;  the  lower  flap  is  reflected  and 
the  deltoid  muscle  is  divided.  The  patient's  hand  is  placed 
on  the  sound  shoulder ;  the  muscles  of  the  vertebral  border 
are  divided,  the  posterior  scapular  artery  is  tied,  and  while 
the  vertebral  border  of  the  scapula  is  pulled  toward  the 
surgeon  the  serratus  magnus  muscle  is  cut,  the  upper  border 
of  the  shoulder-blade  is  cleared,  and  the  suprascapular  artery 
is  tied.  The  hand  is  now  brought  down  to  the  side ;  the 
acromioclavicular  joint  is  disarticulated;  the  conoid  and 
trapezoid  ligaments  are  divided ;  the  muscles  of  the  coracoid 
process  are  cut ;  the  capsule  is  incised,  with  the  supraspinatus 
and  infraspinatus,  the  subscapularis  muscles,  and  the  scapular 
origins  of  the  biceps  and  triceps  ;  and  finally  the  teres  major 
and  minor  muscles  are  divided,  the  subscapular  artery  is  tied, 
and  the  bone  is  removed.  The  wound  is  stitched,  a  drain  is 
introduced,  and  antiseptic  dressings  are  applied.  The  patient 
lies  upon  his  back  until  healing  is  well  under  way,  when  the 
arm  is  placed  in  a  sling.  The  drainage-tube  may  be  removed 
in  twent}'-four  hours. 

Excision  of  a  Rib. — In  caries  the  gouge  and  rongeur  may 
remove  the  disease.  In  other  cases  excision  is  performed. 
In  this  operation  the  patient  lies  upon  his  sound  side.     The 

^  Treves's  Manual  of  Operative  Surgery. 
39 


6 10  DISEASES  AND   IXJfRIES   OF  BOXES  AND  JOINTS. 

surgeon  faces  the  patient.  Make  an  incision  down  to  the 
bone,  in  the  long  axis  of  the  rib.  The  periosteum,  if  not  dis- 
eased, is  Hfted  from  the  bone,  and  the  intercostal  artery  is 
thus  saved  from  being  cut.  After  sawing  the  bone  beyond 
the  limits  of  disease,  remove  it.  During  the  sawing  a  metal 
retractor  is  held  beneath  the  rib,  between  the  rib  and  the 
periosteum.  If  the  periosteum  is  diseased,  remove  it  after 
tying  the  intercostal  artery.  Curet  sinuses.  Pack  with 
iodoform  gauze  for  some  days.  Sew  up  the  wound  except  at 
one  end.  Dress  antiseptically  and  apply  a  binder.  If  a  rib 
is  resected  in  order  to  drain  the  pleural  cavity,  remove  it  by 
the  subperiosteal  section,  ligate  the  artery  after  a  portion  of 
the  rib  has  been  removed,  cut  away  the  periosteum  to  pre- 
vent re -formation  of  bone,  and  open  the  pleura.  (See  Opera- 
tions upon  the  Chest  and  Estlander's  Operation.) 

Complete  Excision  of  One-half  of  the  Upper  Jaw. — 
The  whole  upper  jaw  has  been  removed,  but  in  what  fol- 
lows only  resection  of  one-half  the  jaw  will  be  described. 
This  operation  is  performed  for  malignant  tumors  of  the 
superior  maxillary  bone  or  its  antrum.  Up  to  1826,  at  which 
time  Lizars  of  Edinburgh  suggested  the  operation,  tumors 
of  the  antrum  were  treated  by  scraping  them  away  with  a 
sharp  spoon.  Gensoul  of  Lyons  in  1827  performed  the  first 
operation  for  resection  of  the  upper  jaw.  This  operation  is 
not  justifiable,  except  as  a  palliativ^e  measure,  if  the  orbit  is 
invaded,  if  the  skin  and  subcutaneous  tissues  are  infiltrated, 
or  if  the  disease  extends  beyond  the  superior  maxillary  and 
palate  bones.  The  instruments  required  are  a  mouth-gag ; 
scalpels ;  strong  scissors ;  dissecting,  toothed,  and  hemo- 
static forceps ;  bone-cutting  forceps ;  lion-jaw  and  seques- 
trum-forceps ;  tooth-extracting  forceps  ;  a  volsella  ;  a  narrow- 
bladed  saw ;  a  chisel  and  mallet ;  a  periosteum-elevator ;  a 
spatula  or  metal  retractor ;  Paquelin's  cautery ;  sponges 
which  are  tied  to  sticks;  needles,  curved  and  straight ;  silk 
and  catgut  ligatures  ;  silkworm-sutures  ;  large  curved  needles; 
and  Horsley's  antiseptic  bone-wax. 

Operation  by  Median  Incision. — The  patient,  whose  face  has 
been  shaved,  is  placed  in  the  Trendelenburg  position,  thus 
avoiding  the  possible  need  of  instant  tracheotomy.  The 
surgeon  stands  to  the  right  side  of,  and  faces,  the  pa- 
tient. The  incisor_  tooth  on  the  diseased  side  is  pulled 
out.  The  incision  (Fig.  212,  line  a  b)  is  begun  half  an  inch 
below  the  inner  canthus  of  the  eye,  and  is  carried  along  the 
side  of  the  nose,  around  the  ala  of  the  nose,  by  the  margin 
of  the  nostril,  and  through  the   middle  of  the   lip.     While 


EXC/S/O.V  OF   THE  JAIV. 


6ll 


Fig.  212. — A  B,  excision  of  the  upper 
jaw  ;  c  D  E,  excision  of  the  lower  jaw. 


the  lip  is  being  incised  the  assistant  arrests  hemorrhage 
by  grasping  the  corners  of  the  mouth,  and  after  the  hp  is 
di\'ided  the  coronar}'  arteries  are 
at  once  hgated.  Some  operators 
approach  the  mucous  membrane 
cautiously  and  ligate  the  vessels 
before  opening  the  cavity  of  the 
mouth.  The  upper  portion  of  the 
wound  ha\'ing  been  compressed 
b}-  another  assistant  during  these 
manipulations,  pressure  is  now 
removed  and  bleeding  points  are 
ligated.  Another  incision  is  now 
carried  outward  from  the  begin- 
ning of  the  first  incision,  along  the 
orbital  margin  to  well  over  the 
malar  bone.  The  flap  is  lifted 
from    the    periosteum,    and    the 

bleeding  from  the  infraorbital  arter\^  and  the  small  vessels  is 
restrained  by  pressure.  The  nasal  cartilage  is  separated  from 
the  bone,  and  the  nasal  process  of  the  superior  maxillan,-  is 
sawn  (line  .A.  B,  Fig.  213).  The  orbital  periosteum  is  lifted 
up,  and  the  orbital  plate  is  cut  with 
forceps  from  the  saw-cut  in  the  supe- 
rior maxillar}^  bone  to  the  spheno- 
maxillary fissure  (line  b  c.  Fig.  213). 
The  malar  bone  is  sawn  or  is  bitten 
through  about  its  center,  the  cut 
running  into  the  sphenomaxillar\' 
fissure  and  taking  a  downward  and 
outward  direction  (line  c  d.  Fig.  213). 
The  soft  parts  covering  the  hard 
palate  are  incised  in  the  median  line, 
a  corresponding  incision  is  made 
along  the  floor  of  the  nose  near  the 
septum,  and  the  soft  palate  is  sepa- 
rated from  the  hard  palate  by  a  trans- 
verse cut.  The  saw  is  introduced 
through  the  nose,  and  the  palate  is 
sawn  (line  e,  Fig.  213).  The  upper 
jaw-bone  is  grasped  with  Fergusson's 
lion-jaw  forceps  and  removed,  the 
removal  being  aided  by  the  use  of  the  scissors  and  bone- 
cutters  ;  the  latter  are  used  to  separate  the  upper  jaw  from 
the  pter}-goid  process  (Treves).     Ever}"  vessel  that  can   be 


Fig.  213. — I.  Excision  of  the 
upper  jaw  :  A  B,  section  of  the 
nasal  process  ;  B  c,  section  of  the 
orbital  plate ;  D.  section  of  the 
malar  bone  and  orbital  plate  ;  e, 
section  of  the  alveolus,  and  hard 
palate.  2.  F..xcision  of  the  lower 
jaw:  G,  section  of  the  inferior 
maxillarj' ;  H.  section  of  the 
ramus  in  partial  resection. 


6l2   DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS. 

seen  is  tied,  and  severe  bleeding  from  bone  is  arrested  by 
antiseptic  wax.  Oozing  is  controlled  by  hot  water  and 
pressure  or  by  Paquelin's  cautery.  Examine  carefully  to 
see  if  all  the  diseased  area  is  removed ;  if  it  is  not,  use 
the  gouge,  scissors,  chisel,  and  saw  until  healthy  tissue  is 
reached.  The  wound  is  packed  with  iodoform  gauze,  and 
the  end  of  the  strip  is  so  placed  as  to  be  accessible  through 
the  mouth.  The  wound  is  sutured  (the  mucous  membrane 
of  the  lip  must  be  stitched,  as  well  as  the  skin)  and  is  dressed 
antiseptically  (the  eye  being  protected  by  aseptic  gauze),  and 
a  crossed  bandage  of  the  angle  of  the  jaw  is  applied. 

Excision  of  One-half  of  the  Lo-wer  Ja-w. — In  some  rare 
instances  the  entire  inferior  maxillary  bone  is  removed.  The 
lesions  necessitating  removal  of  the  lower  jaw  are  of  the 
same  nature  as  cause  us  to  remove  the  upper  jaw.  The 
instruments  required  for  removal  of  the  lower  jaw  are  those 
used  for  excision  of  the  upper  jaw,  plus  a  metacarpal  saw 
(having  a  movable  back). 

In  this  operation  the  patient  is  placed  in  the  same  posi- 
tion as  for  excision  of  the  upper  jaw,  the  chin  having 
been  previously  shaved.  A  vertical  cut  is  made  through 
the  chin-tissue,  starting  below  the  margin  of  the  lip  and 
reaching  to  below  the  border  of  the  jaw  (c  d,  Fig.  212). 
From  the  point  d  an  incision  is  carried  outward  below 
the  border  of  the  jaw  and  then  back  of  the  ramus,  as 
shown  in  the  line  d  e  (Fig.  212).  Treves's  advice  is  to 
carry  this  incision  down  to  the  bone,  except  at  the  line 
of  the  facial  artery,  at  which  point  it  must  go  through 
the  skin  only.  The  facial  artery  is  now  to  be  sought 
for,  tied  in  two  places,  and  divided.  The  periosteum  is  lifted 
from  the  external  surface  of  the  bone,  from  the  symphysis 
outward.  Hemorrhage  is  arrested.  The  buccal  mucous 
membrane  is  cut  from  the  alveolus.  A  lateral  incisor  tooth 
is  pulled,  and  the  bone  is  sawn  in  the  line  g  (Fig.  213). 
The  bone  is  grasped  in  a  lion-jaw  forceps  and  is  drawn 
outward.  The  mylohyoid  insertion  is  cut ;  the  internal 
pterygoid  muscle  is  cut  or  the  periosteum  at  this  spot  is 
lifted ;  the  inferior  dental  artery  is  cut  and  tied ;  the  jaw  is 
pulled  down ;  the  insertion  of  the  temporal  muscle  upon  the 
coronoid  process  is  cut  away ;  and  the  external  pterygoid 
muscle  is  divided.  The  capsule  of  the  joint  is  opened,  and 
the  bone  is  separated  from  the  ligaments  which  still  hold  it 
in  place.  Bleeding  is  arrested,  the  wound  is  sutured,  a  tube 
is  introduced  in  the  posterior  portion  of  the  wound  and 
retained  for  twenty-four  hours,  and  antiseptic  dressings  and 


OPERATION  FOR   JIIP-DISLOCATION.  613 

a  Gibson  or  a  Barton  bandage  are  applied.  Partial  excisions 
of  tlie  alveolus  may  be  performed  through  the  mouth  by 
means  of  chisels  and  rongeur  forceps,  and  Wyeth  has  re- 
moved half  of  the  jaw  by  this  method ;  but  if  any  consider- 
able part  of  the  body  of  the  jaw  is  to  be  removed,  it  is  usually 
best  to  make  an  incision  below  the  jaw. 

Operation  for  Congenital  Dislocation  of  Hip. — Hoffa's 
Operation. — The  instruments  used  are  the  same  as  for  a 
resection.  Make  the  external  incision  of  Langenbeck  to 
open  the  joint  (page  604).  The  capsule  is  incised  at  its  inser- 
tion into  the  neck,  and  the  periosteum  and  muscles  are  lifted 
from  the  great  trochanter.  Hoffa  claims  that  in  children 
less  than  five  years  of  age  the  head  can  be  readily  replaced 
into  the  acetabulum  by  flexing  the  thigh  and  making  direct 
pressure  upon  the  head  of  the  bone.  After  replacing  the 
head  it  is  held  in  place  while  an  assistant  extends  the  leg 
in  order  to  stretch  the  muscles.  In  children  over  five  years 
of  age  cut  the  muscles  which  spring  from  the  ischial  tube- 
rosity and  also  the  adductors  with  a  tenotome  ;  cut  the  fascia 
lata  and  muscles  which  arise  from  the  anterior  superior  iliac 
spine  by  incision;  open  the  joint  and  Hberate  the  head; 
remove  the  ligamentum  teres  ;  scrape  out  the  acetabulum, 
removing  "  cartilage,  fat,  and  considerable  spongy  tissue " 
(Tubby);  and  replace  the  head  in  the  acetabulum.  The  limb  is 
maintained  in  inversion,  abduction,  and  extension  for  several 
weeks,  when  it  is  straightened.  Massage  and  passive  motion 
are  begun  in  the  fifth  week.  The  patient  now  gets  about, 
wearing  an  apparatus  for  many  weeks.  This  apparatus  per- 
mits the  head  of  the  bone  to  move  in  the  socket,  but  pre- 
vents redislocation. 

Lorenzs  Operation. — This  is  a  modification  of  Hoffa's. 
The  muscles  inserted  into  the  greater  trochanter  and  the 
lesser  trochanter  are  not  cut ;  the  sartorius,  the  hamstrings, 
and  the  external  portion  of  the  fascia  lata  are  cut  (Tubby). 

The  incision  of  Lorenz  is  longitudinally  from  the  anterior 
superior  spine.  Another  incision  is  carried  inward  from  this 
at  the  level  of  the  lesser  trochanter.  The  capsule  is  opened 
by  a  crucial  cut ;  the  acetabulum  is  enlarged ;  the  head  of 
the  bone,  if  it  remains,  is  inserted  into  the  acetabulum ;  if 
there  is  no  true  head,  a  new  one  is  formed  and  inserted  into 
the  cavity.  The  limb  is  immobilized  in  a  position  of  mod- 
erate abduction.  Massage  and  passive  motion  are  begun  in 
the  fifth  week,  and  are  continued  for  months.^ 

^  I  have  drawn  from  the  very  lucid  description  of  these  operations  in  A.  H. 
Tubby's  treatise  upon  "  Deformities." 


6 14       DISEASES  AND    fXJ CRIES    OE  MUSCLES,    ETC. 

XX.  DISEASES    AND    INJURIES    OF    MUSCLES,    TEN= 
DONS,    AND    BURS/C. 

Myalgia,  or  muscular  rheumatism,  is  a  painful  dis- 
order of  the  voluntary  muscles  and  of  the  fibrous  and  peri- 
osteal areas  where  they  are  attached.  The  term  "  muscular 
rheumatism  "  is  not  strictly  correct.  It  is  possible  that  in 
some  cases  the  muscular  structure  is  inflamed,  but  it  is  cer- 
tain that  in  many  cases  the  pain  is  distinctly  neuralgic. 
Muscular  rheumatism  may  be  due  to  cold  and  wet,  to  over- 
exertion and  strain,  to  acute  infectious  disorders,  to  syphilis, 
to  chronic  intoxications  (lead,  mercury,  and  alcohol),  and  to 
disturbances  of  the  circulation.  Gouty  and  rheumatic  per- 
sons are  especially  predisposed,  men  being  more  liable  to 
the  disease  than  women.  The  disease  is  usually  acute,  but 
it  may  be  chronic. 

Symptoms. — Muscular  rheumatism  is  apt  to  come  on 
suddenly.  The  pain,  which  may  be  very  acute  and  lanci- 
nating or  may  be  dull  and  aching,  is  in  some  cases  con- 
stantly present ;  in  other  cases  it  is  awakened  only  by 
muscular  contraction.  The  pain  is  frequently  relieved  by 
pressure,  though  there  is  often  some  soreness.  The  skin 
above  the  muscle  is  sometimes  tender  to  light  pressure. 
The  disease  usually  lasts  for  a  few  days,  but  it  tends  to  recur. 
There  is  little,  if  any,  fever. 

Lumbago  is  myalgia  of  the  muscles  of  the  loins.  Rlicu- 
matic  torticollis  is  myalgia  of  the  muscles  of  the  neck. 
Usually  one  side  of  the  neck  is  attacked.  The  chin  is  turned 
from  the  affected  side  and  the  neck  is  stiff  Pleurodynia 
is  myalgia  of  the  intercostal  muscles.  The  pain  is  very 
severe,  is  aggravated  by  deep  respiration,  by  coughing,  and 
by  yawning,  there  may  be  tenderness,  and  the  patient  tries 
to  limit  chest-movement.  In  intercostal  neuralgia  the  pain 
is  limited,  is  not  constant,  but  occurs  in  distinct  paroxysms, 
and  is  linked  with  the  presence  of  the  tender  spots  of  Val- 
leix.  Pleurodynia  lacks  the  physical  signs  of  pleurisy. 
Myalgia  must  not  be  confused  with  the  pains  of  locomotor 
ataxia.  Cephalodynia  is  myalgia  of  the  muscles  of  the  scalp. 
The  muscles  of  the  shoulder,  upper  dorsal  region,  abdomen, 
and  extremities  may  also  be  attacked  by  myalgia. 

Treatment. — Remove  any  obvious  cause.  Treat  any  ex- 
isting diathesis,  such  as  gout  or  rheumatism.  Rest  is  of  the 
first  importance.  For  lumbago,  put  the  person  to  bed.  For 
pleurodynia,  strap  the  side  of  the  chest.  A  hypodermatic 
injection  of  morphin  and  atropin  into  the  affected  muscles  at 


INFECTIVE   MYOSITIS.  615 

once  alhu's  the  pain,  and  a  deep  injection  of  distilled  water  is 
sometimes  curative.  The  introduction  of  four  or  five  aseptic 
needles  into  the  muscles,  and  their  retention  for  a  few  minutes, 
sometimes  act  most  favorably.  Ironing  the  skin  above  the  pain- 
ful muscles  is  a  useful  domestic  remedy.  Vigorous  rubbing 
of  the  area  with  a  piece  of  ice  allays  the  pain.  Hot  poultices 
do  good.  If  the  pain  is  widely  diffused,  alters  its  seat,  or  is 
very  obstinate,  order  hot  baths  or  Turkish  baths  and  admin- 
ister diuretics.  In  chronic  cases  employ  blisters  or  counter- 
irritation  by  the  cautery,  give  iodid  of  potassium  and  nux 
vomica,  and  have  the  patient  take  a  Turkish  bath  every 
week.  The  constant  electric  current  finds  advocates.  In 
an  ordinary  severe  case  order  a  hot  bath,  put  the  patient  to 
bed  with  a  hot-water  bag  over  the  part,  and  administer  10 
grains  of  Dover's  powder ;  the  next  morning  order  to  be 
taken  four  times  daily  a  capsule  containing  5  grains  of 
salol  and  3  grains  of  phenacetin,  until  the  pain  disappears. 
Citrate  of  potassium,  citrate  of  lithium,  chlorid  of  ammonium, 
"or  the  salicylate  of  colchicin  may  be  ordered. 

Infective  myositis  is  a  widespread  inflammation  of  the 
voluntary  muscles,  due  to  an  unknown  infecti\'e  cause.  It  is 
a  disorder  accompanied  by  pain  and  stiffness,  by  cutaneous 
edema,  and  by  various  paresthesiae.  Myositis  resembles 
trichinosis,  and  is  distinguished  from  it  only  by  spearing  out 
a  bit  of  muscle  and  examining  it  microscopically.  Occasion- 
ally diffuse  suppuration  occurs.  Ordinary*  myositis  arises 
from  injuries,  from  syphilis,  or  from  rheumatism,  and  it  pre- 
sents the  usual  inflammatory  sym.ptoms.  Contraction  and 
adhesions  may  follow. 

Treatment. — Infective  myositis  is  treated  by  anodynes, 
stimulants,  nutritious  food,  hot  applications,  and  rest.  If 
pus  forms,  it  should  be  evacuated.  Rheumatic  myositis  calls 
for  the  administration  of  the  salicylates,  the  alkalies,  or  salol. 
Syphilitic  myositis  is  treated  with  mercury  and  iodid  of 
potassium.  The  remedies  employed  for  myalgia  are  used 
in  traumatic  myositis. 

Hypertrophy  of  the  muscles  may  arise  from  their  in- 
creased use.  In  pseudohypertrophic  paralysis  the  bulk  of 
the  muscle  is  greatly  augmented,  but  it  contains  less  muscle- 
structure  and  more  fat  or  connective  tissue. 

Atrophy  of  the  muscles  arises  from  want  of  use,  from 
injury,  from  continuous  pressure,  from  interference  with  the 
blood-supply,  from  disease  of  the  nerves  or  their  centers,  or 
from  lead-poisoning. 

Degeneration  of  Muscles. — The  muscles  may  undergo 


6l6       DISEASES  AND   INJURIES    OE  MUSCLES,    ETC. 

granular  degeneration,  waxy  degeneration,  fatty  degenera- 
tion, and  calcareous  degeneration,  and  may  become  pig- 
mented. 

Ivocal  Ossification  and  Myositis  Ossificans. — It  is 
not  unusual  for  a  small  portion  of  bone  to  form  in  the  peri- 
osteal insertion  of  a  muscle  which  is  subjected  to  frequent 
strain.  In  persons  who  ride  many  hours  a  day  there  not 
infrequently  develops  the  "rider's  bone,"  which  is  an  area  of 
ossification  in  the  adductor  muscles  of  the  thigh.  Myositis 
ossificans,  a  widespread  ossification  of  the  muscles,  is  a  rare 
disorder  the  cause  of  which  is  unknown,  and  which  if  not 
congenital  begins  at  least  in  early  life. 

Tumors  of  the  Muscles. — Primary  tumors  of  the  mus- 
cles are  rare.  Among  those  which  may  occur  are  sarcoma, 
fibroma,  lipoma,  osteoma,  angioma,  myxoma,  and  enchon- 
droma.  Most  cases  of  supposed  primary  sarcoma  of  mus- 
cle are  in  reality  cases  of  syphiloma  (Esmarch). 

Syphilis  may  cause  inflammation.  Gummata  may  form, 
or  gummatous  infiltration  may  take  place. 

Trichinosis  or  trichiniasis  is  a  disease  due  to  the 
embryos  of  the  trichina  spiralis.  The  disease  originates 
from  eating  insufficiently  cooked  meat  which  contains  the 
trichinae.  These  nematodes  are  carried  into  the  intestine, 
there  to  develop  and  multiply.  In  from  seven  to  nine 
days  a  horde  of  embryos  develop  in  the  bowel,  and  leave 
the  alimentary  canal  by  passing  through  the  peritoneum  or 
by  means  of  the  blood,  and  finally  reach  the  connective 
tissue  of  the  muscles.  From  the  connective  tissue  the  em- 
bryos migrate  into  the  primitive  muscle-fibers,  where  they 
dwell  and  enlarge.  Myositis  develops,  and  in  the  course 
of  five  or  six  weeks  the  parasites  become  encapsuled  and 
develop  no  further.  The  cyst-walls  may  calcify  and  the  worms 
may  become  calcified,  or  may  live  for  years.  Because  in- 
fected meat  is  eaten  the  disease  does  not  inevitably  develop, 
and  a  few  embryos  lodged  in  muscle  may  cause  no  symp- 
toms. 

Symptoms. — The  symptoms  of  trichinosis  often  appear  in 
a  day  or  two  after  eating  infected  meat.  The  symptoms  of 
acute  gastro-intestinal  catarrh  or  of  cholera  morbus  are  com- 
mon, but  in  some  cases  no  gastro-intestinal  manifestations 
usher  in  the  disease.  In  from  seven  to  fourteen  days  after  the 
infected  meat  is  eaten  the  migration  of  the  parasites  develops 
obvious  symptoms.  A  chill  may  be  noted ;  tliere  is  usually 
fever ;  muscular  pain,  tenderness,  swelling,  and  stiffness  are 
complained  of    This  condition  may  be  widespread.     Involve- 


U'Oi'XDS  AXD    CONTUSIONS   OF  MUSCLES.  617 

mcnt  of  the  muscles  of  mastication  interferes  with  cliewing ; 
of  the  larynx,  with  audition  and  respiration  ;  of  the  mter- 
costals  and  diaphragm,  with  respiration.  Skin-edema  and 
itching  are  marked.  In  some  cases  dehnum  exists.  The 
writer  saw  in  the  Philadelphia  Hospital  one  fatal  case  which 
was  mistaken  for  eiysipelas  because  of  the  high  fever,  the 
delirium  and  the  edematous  redness  of  the  face  and  neck. 
Dyspnea  is  frequent.  Mild  cases  get  well  in  a  week  or  tAxo ; 
severe  cases  may  last  many  weeks.  The  mortality  varies 
in  different  epidemics  from  i  to  30  per  cent.  (Osier).  The 
diagnosis  is  made  by  spearing  out  a  piece  of  muscle,  which 
is  then  examined  for  trichinae  under  a  microscope  ;  or  the 
worm  may  be  detected  in  the  feces  by  means  of  a  pocket- 
lens.  .  , 

Treatment.— To  treat  trichinosis  employ  purgatives 
(senna  and  calomel)  earh"  m  the  case,  and  give  glycerin, 
and  also  santonin  or  filix  mas.  When  muscular  invasion 
has  taken  place,  sedatives,  hypnotics,  nourishing  diet,  and 
stimulants  are  indicated. 

Wounds  and  Contusions  of  the  Muscles.— n^?/^/^^' 
of  muscles  may  be  either  open  or  sitbaitaneous.  In  a  longi- 
tudinal wound  the  edges  lie  close  together,  and  hence  drain- 
acre  must  be  provided  for  by  the  surgeon.  In  a  transverse 
w^ound  the  edges  separate  widely,  and  catgut  stitches  must 
be  inserted  Contusions  of  muscles,  like  contusions  of  other 
tissues,  vary  in  extent  and  in  severity.  There  are  pam  (which 
is  increased  by  attempts  to  use  the  muscle),  loss  of  function, 
swelling  beneath  the  deep  fascia,  and  discoloration,  which 
mav  appear  at  once  because  of  superficial  damage  from  the 
initial  mjurv,  or  which  may  appear  in  dependent  parts  after 
manv  days  by  gravitation  of  the  blood  and  the  blood-stained 
serum.  As  a  result  of  contusion,  suppuration,  inflammation, 
or  atrophy  may  arise. 

Treatment.— The  indications  in  wounds  and  contusions 
of  muscles  are  to  obtain  rest  by  means  of  splints  and  to 
secure  relaxation.  Limitation  of  swelling  is  secured  by 
bandaging.  Inflammation  is  combated  first  by  cold  and  lead- 
water  and  laudanum;  later  by  iodin,  blue  ointment,  ichthyol, 
and  intermittent  heat.  To  prevent  loss  of  function  employ, 
as  soon  as  the  acute  symptoms  subside,  massage,  passive 
motion,  and  stimulating  liniments,  and.  later  in  the  case,  elec- 
tricit)'  (galvanism  if  the  reactions  of  degeneration  exist, 
faradism  if  they  are  absent).  . 

Strains  and  Ruptures.— A  strain  is  a  stretching  ot  a 
muscle  with  a  small  amount  of  rupture.     The  muscle  is 


6l8       DISEASES  AND   INJURIES    OF  MUSCLES,    ETC. 

swollen,  tender,  stiff,  weak,  and  sore,  and  attempts  at  motion 
produce  sharp  pain.  Strains  are  common  in  the  deltoid,  the 
hamstring  muscles,  the  back,  the  calf,  the  biceps,  and  the 
great  pectoral.  Strain  of  the  psoas  muscle  causes  pain  on 
flexing  the  thigh,  and  is  associated  with  tenderness  in  the 
iliac  fossa.  Strain  of  the  right  psoas  may  be  mistaken  for 
appendicitis,  but  it  lacks  the  intense  local  tenderness,  the 
abdominal  rigidity,  and  the  constitutional  symptoms.  "  Lawn- 
tennis  arm  "  is  a  strain  of  the  pronator  radii  teres  muscle. 
"  Riders'  leg "  is  a  strain  of  the  adductor  muscles  of  the 
thigh.  A  strain  may  be  the  only  injury,  or  may  be  asso- 
ciated with  some  other  condition  (fracture  of  bone,  disloca- 
tion, sprain,  contusion,  etc.).  A  strain  may  be  followed  by 
periostitis  at  the  point  of  insertion  of  the  muscle. 

The  muscle  is  often  rigid,  is  tender,  and  pains  greatly 
when  an  attempt  is  made  to  use  it.  The  skin  over  it,  espe- 
cially over  its  point  of  insertion,  is  usually  tender. 

A  strain  of  the  back  is  a  very  common  accident  which  is 
often  associated  with  sprains  of  the  vertebral  ligaments. 
There  is  great  pain  when  the  patient  voluntarily  straightens 
up.  If  the  vertebral  ligaments  are  not  sprained,  the  patient 
can  be  straightened  by  passive  motion  without  pain.  The 
skin  is  tender  in  certain  areas.  The  muscles  are  often  rigid. 
There  may  be  unilateral  rigidity.  In  a  back  injury  make  a 
careful  examination  to  be  sure  there  is  no  damage  to  ver- 
tebra or  cord. 

Treatment. — Relaxation  by  suitable  position  ;  rest  by  the 
use  of  splints  or  by  putting  the  patient  to  bed ;  bandages 
for  compression  ;  hot  fomentations  or  a  hot-water  bag,  or 
ichthyol.  As  soon  as  acute  symptoms  subside  employ  fric- 
tions and  massage.  If  there  is  much  pain  after  a  strain, 
administer  Dover's  powder,  or  even  morphin. 

Rupture  of  a  muscle  is  announced  by  a  sudden  and  vio- 
lent pain  and  by  loss  of  function  arising  during  powerful 
muscular  contraction  or  strong  traction  on  a  muscle.  The 
rupture  may  be  announced  by  a  clearly  audible  snap  (A. 
Pearce  Gould).  A  distinct  gap  is  felt  between  the  ends  ; 
great  pain  develops  on  movement ;  there  are  tenderness, 
loss  of  power,  and  swelling.  Strains  and  ruptures  may  be 
followed  by  atrophy,  as  are  contusions.  Among  the  mus- 
cles which  occasionally  rupture  we  may  mention  the  quad- 
riceps, biceps,  triceps,  deltoid,  plantaris,  etc. 

Treatuicnt. — In  limited  rupture  treat  as  a  severe  strain. 
In  treating  extensive  rupture  of  an  important  miuscle,  when 
the    ends    are    widely  separated,    incise  with    every  aseptic 


DISLOCATION   OF  MUSCLES  AND    TENDONS.         619 

care,  unite  the  divided  ends  with  sutures  of  chromic  catgut, 
and  sew  up  the  skin  with  silkworm-gut.  Treat  the  part  in 
any  case  by  rest  and  relaxation,  and  combat  inflammation 
by  appropriate  means.  Passive  motion  and  massage  are 
employed  as  soon  as  union  is  firm.  In  rupture  of  the  quad- 
riceps extensor  femoris,  operation  should  be  undertaken, 
because  mechanical  treatment  gives  frequently  a  bad  result 
and  confines  the  patient  to  bed  for  many  weeks. 

Hernia  of  Muscles.— When  a  tear  takes  place  in  a 
muscular  sheath  a  portion  of  the  muscle  protrudes.  The 
treatment  is  incision  and  the  stitching  of  the  sheath. 

Contractions  of  muscles  may  result  from  injury,  from 
joint-disease,  from  malposition  of  parts  (as  in  old  dislocation 
or  torticollis),  or  from  diseases  of  the  nervous  system.  The 
treatment  in  some  cases  is  sudden  extension,  in  other  cases 
gradual  extension,  tenotomy,  or  myotomy.  Macewen  recom- 
mends the  making  of  a  number  of  V-shaped  incisions  in 
the  muscle.  In  some  cases  of  spasmodic  contraction  nerve- 
stretching  is  of  value. 

Dislocation  of  Muscles  and  Tendons. — The  long 
head  of  the  biceps  is  oftenest  displaced.  The  flexor  carpi 
ulnaris,  the  peroneus  brevis,  the  peroneus  longus,  the 
tibialis  posticus,  the  sartorius,  the  plantaris,  the  quadriceps 
extensor  femoris,  and  the  extensors  back  of  the  wrist  may 
be  dislocated.  What  is  known  as  dislocation  of  the  latis- 
simus  dorsi,  a  condition  in  which  that  muscle  no  longer  lies 
upon  the  angle  of  the  scapula,  is  not  a  dislocation,  but  a 
paralysis.  Most  of  these  accidents  are  associated  with 
chronic  joint-disease  or  with  fracture,  but  displacement  may 
exist  as  a  solitary  injury.  Dislocation  of  the  long  head  of 
the  biceps  may  occur  tolerably  early  in  the  progress  of  rheu- 
matoid arthritis  of  the  shoulder-joint,  and  the  displaced 
tendon  may  be  absorbed. 

Symptoms. — After  dislocation  of  a  tendon  the  muscle  of 
the  tendon  can  still  contract,  but  it  acts  at  a  disadvantage ; 
thus  the  corresponding  joint  exhibits  partial  loss  of  function. 
The  displaced  tendon  can  be  felt,  and  a  hollow  exists  where 
it  normally  resides. 

When  the  muscle  contracts  the  tendon  is  felt  to  slip  from 
its  groove.  When  the  tendon  of  the  biceps  is  dislocated 
the  head  of  the  bone  passes  forward  (so-called  subluxation 
of  the  humerus). 

Treatment. — In  tendon-dislocation  reduction  is  easy,  but 
the  displacement  is  apt  to  recur  because  of  laceration  of  the 
sheath.     The  treatment  usually  advised  is  to  effect  reduction 


620       DISEASES  AND   INJURIES   OF  MUSCLES,    ETC. 

by  relaxation  of  the  limb  and  manipulation  of  the  tendon, 
to  place  the  part  upon  a  splint  so  that  the  muscle  belonging 
to  the  tendon  will  be  relaxed,  and  to  apply  pressure  over  the 
point  of  injury.  This  treatment  generally  fails,  and  if  the 
tendon  does  not  become  anchored  in  its  proper  situation 
firmly  in  four  weeks  we  should  operate.  In  some  tendons 
it  is  enough  to  incise,  freshen  the  edges  of  the  torn  sheath, 
and  sew  up  with  kangaroo-tendon  or  chromic  catgut.  In  a 
tendon  lying  in  a  long  groove,  make  a  halter  for  the  tendon 
by  incising  the  periosteum  and  suturing  it  over  the  tendon.^ 
Passive  movements  are  begun  at  the  end  of  the  first  week. 
Even  if  the  tendon  will  not  remain  reduced,  a  useful  joint 
will  be  obtained.  Wood  of  New  York  advised  in  obstinate 
cases  tenotomy  and  immobilization. 

Wounds  of  Tendons. — Subcutaneous  wounds  of  ten- 
dons are  usually  inflicted  by  the  surgeon,  and  they  heal 
well.  Open  wounds  require  rigid  antisepsis  and  suturing 
of  the  tendon.  In  wounds  of  the  wrist  especially  always 
suture  the  tendons  (Fig.  2i8),  and  be  sure  to  bring  the  proper 
ends  into  apposition. 

Rupture  of  Tendons. — A  violent  muscular  effort  may 
rupture  a  tendon,  and  as  the  accident  occurs  a  snap  may 
often  be  heard.  The  symptoms  are  sudden  pain  and  loss  of 
power,  fulness  of  the  associated  muscle  from  retraction,  and 
absolute  inability  to  bring  the  tendon  into  action.  A  gap 
may  often  be  felt  in  the  tendon. 

Treatment. — The  best  procedure  in  treating  rupture  of  a 
tendon  is  exposure  by  incision  and  the  introduction  of 
sutures.     Some  surgeons  relax  the  parts  and  apply  splints. 

Thecitis,  or  tenosynovitis,  is  inflammation  of  the 
sheath  of  a  tendon. 

Acute  thecitis  may  arise  from  a  contusion,  from  a  wound, 
from  repeated  over-action  in  working,  from  rheumatism, 
from  gonorrhea,  from  influenza,  from  the  continued  fevers, 
or  from  syphilis.  In  early  syphilis  certain  tendon-sheaths 
may  rapidly  develop  effusion  because  of  hyperemia  of  the 
sheaths  (Taylor). 

Sym.ptorQS. — In  nonsuppurative  cases  of  thecitis  the 
symptoms  are  pain,  swelling,  tenderness,  and  moist  crepitus 
along  the  tendon-sheath,  due  to  inflammatory  roughening. 
The  crepitus  disappears  as  the  swelling  increases,  but  it 
reappears  as  the  swelling  diminishes.  In  suppurative  cases 
the  symptoms  are  great  swelling,  pulsatile  pain,  dusky  dis- 

'  Walsham's  case  of  dislocation  of  peroneous  longus,  Brit.  Med.  Jou7\,  Nov. 
2,   1895. 


PALMAR   ABSCESS. 


621 


coloration,  inflammation  spreading   up  the   tendon-sheaths, 
and  often  the  constitutional  symptoms  of  sepsis. 

Treatment. — In  treating  non-suppurative  thecitis,  employ- 
splints  and  apph'  locally  iodin,  blue  ointment,  or  ichthyol, 
and  administer  suitable  remedies  to  combat  any  causative 
constitutional  disease.  In  the  suppurative  form  make  free 
incisions,  irrigate,  drain,  and  dress  with  hot  antiseptic  fomen- 
tations. 

Palmar  Abscess. — A  thecal  abcess  about  the  flexor 
tendons  of  the  fingers  travels  rapidly  upward  and  is  apt  to 
produce  a  palmar  abscess.  A  thecal  abscess  of  either  the  in- 
dex, ring,  or  middle  finger  is  usually  arrested  at  the  lower  end 
of  the  palm,  but  suppurative  the- 
citis of  the  thumb  or  the  little 
finger  may  diffuse  pus  over  a  large 
surface  of  the  palm  and  also 
up  the  arm  (Fig.  214).  Palmar 
abscess  is  a  most  serious  affec- 
tion. The  pus  may  dissect  up 
all  the  structures  of  the  palm, 
may  reach  the  dorsum,  or  may 
pass  beneath  the  anterior  annular 
ligament  into  the  connective-tis- 
sue planes  of  the  forearm. 

Treatment. — A  palmar  abscess 
demands  free  incision  and  drain- 
age at  the  earliest  possible  mo- 
ment. The  patient  should  be 
placed  under  the  influence  of 
ether.  The  incision  is  made  in 
the  line  of  the  metacarpal  bone 
and,  if  possible,  below  the  palmar 
arches.  A  line  transverse  with 
the  web  of  the  thumb  is  below 
the  palmar  arches.  In  an  inci- 
sion above  this  line,  tr\'  not  to 
cut  either  arch ;  but  if  one  be  cut,  at  once  take  means  to 
arrest  the  hemorrhage  (page  336).  In  a  severe  case  it  may 
be  necessary  to  make  several  palmar  incisions,  to  open  the 
tendon-sheaths  on  the  flexor  surface  of  the  forearm  abo\'e 
the  wrist,  and  to  make  counteropenings  in  the  back  of  the 
hand.  In  severe  cases  it  is  necessary  to  introduce  tubes, 
and  drain  through  and  through.  After  operation  apply  hot 
antiseptic  fomentations  and  put  the  part  upon  a  splint. 
When  granulations  begin  to  form  dry  dressings  are  substi- 


FiG.  214. — Diagram   of  tendon-sheaths 
of  the  hand   (Tillaux). 


622       DISEASES  AND   INJURIES    OF  MUSCLES,    ETC. 

tuted  for  the  hot  moist  dressing.  It  may  be  necessary  to 
give  morphin  for  pain,  and  stimulants  may  be  needed.  There 
is  great  danger  of  stiffness  of  the  fingers  occurring,  the  ten- 
dons becoming  adherent  to  their  sheaths.  Hence,  begin 
passive  movements  as  soon  as  granulations  begin  to  form. 

Chronic  thecitis  may  follow  acute  thecitis,  but  may  be 
due  to  injury,  to  rheumatism,  to  gummatous  infiltration,  to 
rheumatoid  arthritis,  or  to  a  tubercular  inflammation  of  a 
tendon-sheath  (compound  ganglion).  In  tubercular  thecitis 
the  swelling  is  firm  or  doughy  when  due  to  granulation-tis- 
sue, but  is  fluctuating  when  due  to  fluid.  Grating  is  marked. 
The  tendon-sheath  may  contain  numerous  small  bodies  which 
are  either  free  or  are  attached  (rice,  riziform,  or  melon -seed 
bodies).  Tubercle  bacilli  are  present  in  the  fluid  or  in  the 
granulation-tissue.  Chronic  thecitis  is  commonest  in  the  ten- 
dons of  the  fingers,  the  ankles,  and  the  knees ;  it  may  spread 
to  a  joint  or  it  may  arise  from  a  tubercular  joint.  This 
condition  causes  very  little  pain.  In  ordinary  non-tuber- 
cular thecitis  the  part  is  weak,  tender,  painful,  and  stiff,  crepi- 
tates on  motion,  and  is  swollen. 

Treatment. — Tubercular  cases  are  treated  as  follows  :  in 
cases  in  which  there  is  fluid  effusion  make  a  small  incision, 
wash  out  with  salt  solution,  introduce  some  iodoform  emul- 
sion, and  close  the  wound.  In  cases  in  which  there  are  rice- 
bodies,  open  the  sheath,  evacuate  the  contents,  scrape  the 
walls  thoroughly,  inject  with  iodoform  emulsion,  and  close 
the  wound.  (If  the  annular  ligament  requires  division, 
stitch  it;  Fig.  221.)  In  cases  wath  extensive  formation  of 
embryonic  tissue  apply  an  Esmarch  bandage,  make  a  large 
incision,  and  remove  all  infected  tissue  from  the  sheath, 
around  the  sheath,  and  from  the  tendon.  In  an  ordinary  trau- 
matic thecitis  use  for  the  first  few  days  rest  associated 
with  applications  of  ichthyol.  Later  employ  hot  and  cold 
douches,  massage,  and  passive  movements,  strapping  of  the 
part,  inunctions  of  ichthyol,  and  the  hot-air  bath.  If  effu- 
sion is  persistent  or  rice-bodies  exist,  make  an  incision  and 
scrape  the  interior  of  the  tendon-sheath.  In  rheumatic  cases 
give  antirheumatic  remedies  and  employ  the  hot-air  bath.  In 
syphilitic  cases  administer  mercury  and  iodid  of  potassium. 

Ganglia. — In  connection  with  tendon-sheaths  simple 
ganglia  may  develop.  They  are  small,  tense,  round  swell- 
ings, which  are  firm,  grow  progressively  though  slowly,  are 
painless  when  uninflamed,  and  contain  a  fluid  of  the  appear- 
ance and  consistence  of  glycerin-jelly  (Bowlby).  Ganglia 
are    commonest    upon  the  dorsum  of  the   wrist,   and    they 


FELOX,    OK    WHITLOW.  623 

occur  especially  in  those  who  constantly  use  the  wrist-mus- 
cles. Paget  states  that  a  simple  ganglion  is  due  to  cystic 
degeneration  of  a  synovial  fringe  inside  a  tendon-sheath,  and 
that  the  fluid  of  the  ganglion  does  not  communicate  with  the 
fluid  of  the  tendon-sheath.  Others  pathologists  believe  a  sim- 
ple ganglion  to  be  a  hernia  of  synovial  membrane  through  a 
rent  in  a  tendon-sheath,  all  communication  between  the  her- 
niated part  and  the  tendon-sheath  being  soon  obliterated. 
Coviponiid  ganglion  is  an  old  name  for  tubercular  thecitis. 

Treatment. — A  ganglion  is  treated  by  aseptic  puncture 
with  a  tenotome,  evacuation,  scarification  of  the  walls,  antisep- 
tic dressing,  and  pressure.  An  old-time  method  of  treatment 
w^as  subcutaneous  rupture  brought  about  by  striking  with  a 
heavy  book.  Duplay  treats  a  ganglion  by  injecting  a  few 
drops  of  iodin  through  a  hypodermatic  needle.  The  cyst  is 
not  evacuated  before  injection.  The  parts  are  dressed  anti- 
septically,  and  cure  is  obtained  in  one  week.  Recurrent 
ganglia,  very  large  ganglia,  and  ganglia  with  very  thick 
contents  should  be  dissected  out. 

Felon,  or  whitlow,  is  a  violent  rapidly  spreading  pyo- 
genic inflammation  of  a  finger  or  a  foe  which  resembles 
cellulitis,  and  which  is  sometimes  followed  by  gangrene  or 
_by_jie£rosis_of  bone.  As  a  rule,  an  injury  precedes  the 
w^hitlow,  an  abrasion  of  the  surface  which  admits  pus-organ- 
isms or  a  contusion  which  creates  a  point  of  least  resistance. 
The  commonest  seat  of  a  felon  is  the  last  digit  of  the  finger 
oi'  thumb.  An  abrasion  of  the  surface  at  this  point  absorbs 
pus-organisms  and  the  superficial  lymphatics  carry  them 
directly  inward,  lodging  them,  it  may  be,  in  the  skin,  in  the 
subcutaneous  tissues,  in  the  tendon-sheath,  or  beneath  the 
42eriQsteum. 

Felons  are  very  rare  in  infants,  but  may  occur  in  children. 
Women  are  more  liable  to  them  than  are  men.  The  fingers 
are  much  more  liable  to  infection  than  are  the  toes,  because 
they  are  more  exposed  to  injury.  Several  fingers  ma}'  be 
attacked  at  once  or  successively  in  persons  of  dilapidated 
constitution.  Whitlow  is  most  apt  to  occur  and  is  most 
severe  in  persons  broken  down  by  disease,  alcoholism,  over- 
work, or  worry.  In  certain  cases  of  neuritis  painless  sup- 
puration may  arise. 

There  are  two  forms  of  felons,  the  superjicial  and  the  deep. 

If  the  infection  is  in  the  skin,  the  point  of  infection  becomes 
dark  red,  swollen,  painful,,  and  tender.  The  epidermis  Ls 
lifted  up  by  the  pus  which  forms,  and  a  considerable  area 
may  be  attacked  before  the  spread  of  the  process  is  arrested. 


624       DISEASES  AND   INJURIES   OF  MUSCLES,    ETC. 

If  the  subcutaneous  tissues  only  are  involved,  the  symptoms 
are  those  of  an  ordinary  celluHtis.  Paronychia  is  a  celluHtis 
starting  at  the  end  or  side  of  the  digit,  and  involving  the  parts 
around  and  below  the  nail.  The  pus-organisms  obtain  en- 
trance by  means  of  an  abrasion,  a  puncture,  or  an  ulcerated 
"  step-mother."  The  pain  is  throbbing  and  violent ;  is  in- 
creased by  motion.,  pressjore^or  a  dependent_position  ;  the  skin 
is  dusky  red,  but  the  swelling  is  slight.  In  about  forty-eight 
hours  pus  forms  in  the  superficial  parts,  the  epidermis  being 
lifted  into  pustules  or  blebs,  and  pus  may  also  form  under  the 
nail.    A  portion  of  the  nail,  or  the  entire  nail,  may  be  lost. 

If  the  tendon-sheath  is  involved  as  well  as  the  subcu- 
taneous tissue,  the  symptoms  are  those  of  suppurative  cellu- 
litis, with  more  marked  discoloration  and  tenderness  and 
more  pulsatile  pain. 

Deep  felon,  or  bone-felon,  involves  most  of  the  structures 
of  the  Anger  (periosteum,  bone,  tendon,  tendon-sheath,  and 
cellular  tissue),  and  may  destroy  the  digit  or  the  finger.  It 
arises  in  the  same  manner  as  paronychia,  but  the~  organisms 
are  lodged  in  the  deeper  parts.  The  pain  is  agonizing,  en- 
tirely preventing  sleep,  pulsatile  in  character,  associated  with 
excruciating  tenderness,  greatly  aggravated  by  motion  or  a 
dependent  position,  and  often  extending  up  the  hand  and  fore- 
arm. The  skin  is  dusky  red  and  edematous,  and  the  part  is 
enormously  swollen.  Pus  forms  quickly;  diffuse  cellulitis 
may  arise  ;  thecal  suppuration  may  occur ;  sloughing^ of  the 
tendon  and  subcutaneous  tissue  may  take  place ;  necrosis  of 
onej)rjTiore-.bones  may^nsue,  and  in  some  cases  gangrene 
of  the  finger  follows. 

In  deep  whitlow  lymphangitis  of  the  forearm  and  arm  is  not 
unusual,  adenitis  of  the  axillary  glands  is  common,  and  almost 
always  there  is  fever.  In  superficial  felon  constitutional 
symptoms  are  slight  or  absent,  and  lymphangitis  and  adenitis 
arise  in  a  minority  of  cases.  A  felon  may  be  followed  by  a 
palmar  abscess,  and  is  particularly  apt  to  be  if  the  disease 
arises  in  the  thumb  or  little  finger. 

Treatment. — Even  a  superficial  felon  demands  instant  inci- 
sionin  all  cases,  and  the  parts  must  be  irrigated,  dressed  with 
Hot  antiseptic  fomentations,  and  the  hand  must  be  placed  upon 
a  splint.  A  bone-felon  requires  prompt  incision  to  the  bone 
alongside  the  tendon.  Fig.  215  shows  the  proper  lines  of 
incision  in  the  fingers  and  palm.  Do  not  wait  for  pus  to 
form,  but  allay  tension  and  prevent  pus-formation  by  early 
incision.  Do  not  waste  time  with  poultices  :  to  wait  means 
agonizing  pain,  sleepless  nights,  constitutional  invplvement, 


BURSITIS. 


625 


and,  perhaps,  sloughing  of  tendons  or  death  of  bone.  Inci- 
sion and  drainage  constitute  tJie  treatment,  followed  by  irri- 
gation, antiseptic  fomentations,  and  splinting  of  the  extrem- 
ity. If  the  patient  cannot  steep,  give  morphin.  See  that  the 
bowels  are  moved  once  a  day. 
Give  quinin,  iron,  and  milk  punch. 
Opening  a  felon  is  exquisitely  pain- 
ful ;  hence  ether  should  be  given 
in  the  -first  stage,  nitrous  oxid 
should  be  administered,  or  the 
superficial  parts  should  be  frozen 
by  a  spray  of  chlorid  of  ethyl. 

Bursitis  is  inflammation  of  a 
bursa.  Acute  bursitis  arises  from 
strain  or  from  traumatism.  The 
symptoms  of  acute  bursitis  are 
pain,  limited  swelling,  moist  crep- 
itus, fluctuation,  and  discolora- 
tion in  the  anatomical  position  of 
a  bursa.  Bursitis  of  the  retro- 
calcaneal  bursa  (Albert's  disease) 
is  a  painful  affection  which  is  often 
overlooked.  Walking  causes  great 
pain  in  the  heel.  Raising  up  on  the 
toes  is  excessively  painful.  It  is  usually  associated  with  flat 
foot.  In  these  cases  osteophytes  often  form  within  the  bursa. 
There  are  numerous  bursa  about  the  hip.  Some  anatomists 
count  twenty-one.^  The  two  most  important  bursae  and  the 
ones  usually  affected,  are  the  iliac  and  the  deep  bursa  over 
the  great  trochanter.^  Inflammation  of  the  iliac  bursae  pro- 
duces swelling  below  Poupart's  ligament,  which  swelling  is 
tense,  but  exhibits  fluctuation  on  careful  examination.  In 
some  cases  the  sac  can  be  emptied  by  pressure,  the  fluid 
passing  into  an  adjacent  bursa  or  into  the  joint.  The 
enlargement  often  presses  on  the  anterior  crural  nerve  and 
causes  pain  throughout  the  nerve's  trajectory.  The  limb, 
according  to  Zuelzer,  is  usually  slightly  flexed,  abducted 
and  rotated  outward,  and  movement  in  an  opposite  direction 
causes  pain.  Inflammation  of  the  bursae  about  the  hip  may 
produce  symptoms  resembling  those  of  incipient  coxalgia,  but 
in  bursitis  the  symptoms  do  not  remit  as  in  hip-disease.  In 
inflammation  of  the  gluteal  bursae  there  is  moderate  pain 
back  of  the  thigh  and  knee  which  disappears  when  the  patient 
is  at  rest ;  there  is  a  marked  limp,  limitation  of  motion,  and  an 

^  Synnestvedt,  of  Sweden.  ^  Zuelzer,  in  Zeit.  f.  Chir.,  vol.  1. 

40 


Fig.  215. — I,  2,  and  3,  Incisions  for 
felon  of  finger  and  for  ordinary  suppu- 
ration ;  4,  palmar  incision. 


626       DISEASES  AND   INJURIES    OF  MUSCLES,    ETC. 

area  of  deep  fluctuation  in  the  buttock  (Brackett).  In  in- 
flammation of  the  iliac  bursae  flexion  is  not  so  marked  as 
in  coxalgia,  and  the  trochanter  is  never  above  Nelaton's  hne. 
In  inflammation  of  the  deep  trochanteric  bursa  the  position 
is  the  same  as  in  ihac  bursitis,  and  resembles  that  of  coxalgia. 
In  coxalgia,  however,  there  is  pain  on  pressure  upon  the  front 
of  the  joint  or  directly  on  the  trochanter  or  on  tapping  the 
sole  of  the  foot.  These  manipulations  do  not  cause  pain  in 
bursitis  (Zuelzer). 

It  is  difficult  to  differentiate  between  inflammation  of  a 
deep  bursa  and  synovitis ;  indeed,  in  bursitis  the  joint  is  apt 
to  be  secondarily  affected.  This  difficulty  is  especially  vexa- 
tious in  distinguishing  between  joint-injury  and  injury  of  the 
bursa  beneath  the  deltoid.  Suppuration  may  take  place  in  a 
bursa.  Direct  force  may  rupture  a  bursa.  The  bursa  beneath 
the  deltoid  is  frequently  ruptured.  When  this  accident  hap- 
pens there  are  pain,  marked  swelling,  a  large  area  of  moist 
crepitus,  and  later  extensive  discoloration  from  blood. 
Clironic  bursitis  may  follow  acute  bursitis,  or  the  disease 
may  be  chronic  from  the  start.  Its  symptom  is  swelling 
with  little  or  no  pain  unless  acute  inflammation  arises. 
Chronic  bursitis  of  the  subhyoid  bursa  is  known  as  Boyer's 
cyst. 

Treatment. — Acute  bursitis  is  treated  by  rest,  pressure, 
and  the  application  of  iodin,  blue  ointment,  or  ichthyol.  If 
the  swelling  persists,  aspirate  and  apply  pressure,  or  incise 
the  sac  and  remove  it  partly  or  completely.  If  pus  forms, 
incise,  paint  the  interior  of  the  sac  with  pure  carbolic  acid, 
and  pack  with  iodoform  gauze.  Chronic  bursitis  may  be 
cured  by  the  use  of  pressure  and  the  application  of  blue 
ointment,  and  with  treatment  of  any  causative  diathesis  ;  but 
most  cases  require  incision  and  packing.  A  ruptured  bursa 
is  treated  as  an  acute  bursitis.  Some  cases  of  retrocalcaneal 
bursitis  get  well  from  rest,  but  others  demand  incision  and 
drainage.  If  osteophytic  formation  takes  place  in  Albert's 
disease,  remove  the  bony  stalactites  with  a  rongeur  forceps 
or  a  gouge. 

Housemaids'  knee  is  thickening  and  enlargement  of  the 
prepatellar  bursa,  due  to  intermittent  pressure  (Fig.  216). 
In  effusion  into  the  knee-joint  the  fluid  is  behind  the  patella 
and  the  bone  floats  up  ;  in  housemaids'  knee  the  fluid  is  above 
the  bone  and  the  osseous  surface  can  be  felt  beneath  it. 
"  Miners'  elbow,"  which  is  a  condition  similar  to  housemaids' 
knee,  affects  the  olecranon  bursa.  "  Weavers'  bottom  "  is 
enlargement  of  the  bursa  over  the  tuberosity  of  the  ischium. 


BUNION. 


627 


A  bursa  which  is  simply  thickened  and  enlarged  rarely  gives 
rise  to  annoyance ;  but  when  it  inflames,  as  it  is  apt  to  do,  it 
causes  the  ordinary  symptoms  of  bursitis. 

Treatment. — Some  few  cases  of  housemaids'  knee  may 
be  cured  by  rest  and  blistering,  but  in  most  cases  it  is  neces- 
sary to  incise  and  pack  with  iodoform  gauze.     In  enlargement 


Fig.  216. — Housemaids'  knee. 


of  the  bursa  beneath  the  Hgamentum  patallae,  if  rest  and 
blistering  fail  to  cure,  aspirate  or  incise.  In  enlargement  of 
the  bursa  beneath  the  tendon  of  the  semimembranosus  and 
also  in  "  weavers'  bottom  "  incise  and  pack. 

Bunion. — A  bunion  is  a  bursa  due  to  pressure,  and  it  is 
most  commonly  situated  above  the  metatarsophalangeal 
articulation  of  the  great  toe,  but  is  occasionally  seen  over  the 
joint  of  another  toe.  When  the  big  toe  is  pushed  inward 
by  ill-fitting  boots  a  bunion  forms.  When  a  bunion  is  not 
inflamed  it  may  cause  but  little  trouble,  but  when  it  inflames 
the  bursa  enlarges  and  the  parts  become  hot,  tender,  and 
excessively  painful.     Suppuration  may  occur  and  pus  may 


628       DISEASES  AND   INJURIES    OF  MUSCLES,    ETC. 

invade  the  joint,  and  the  bone  not  unusually  becomes  dis- 
eased. 

Treatment. — In  treating  a  bunion  the  patient  must  wear 
shoes  that  are  not  pointed,  that  have  the  inner  borders 
straight,  and  that  have  rounded  toes  (Jacobson).  For  a 
mild  case  a  bunion-plaster  gives  comfort.  Sayre  advises 
the  use  of  a  linen  glove  over  the  digits,  the  phalanges  being 
drawn  inward  by  a  piece  of  elastic  webbing,  one  end  of  which 
is  fastened  to  the  glove  and  the  other  end  to 
a  piece  of  strapping  from  the  heel.  A  special 
apparatus  may  be  worn  (Fig.  217).  In  many 
cases  osteotomy  of  the  first  phalanx  or  of  the 
first  metatarsal  bone  is  required ;  in  some 
cases  excision  of  the  joint  is  necessary;  in 
others  amputation  must  be  performed.  When 
the  bursa  is  not  inflamed,  but  only  thickened, 
blisters  should  be  employed  over  it,  or  there 
app'a'^aturfor^'bun-  should  be  applied  tincture  of  iodin,  ichthyol, 
'°°^-  or  mercurial  ointment.     When  the  bursa  in- 

flames, ichthyol  ointment  is  applied,  and  intermittent  heat  by 
foot-baths  gives  relief  Suppuration  demands  immediate  in- 
cision and  antiseptic  dressing.  If  an  ulcerated  bunion  does 
not  heal  by  antiseptic  dressing,  stimulate  it  with  silver  and 
dress  it  with  ungent.  hydrarg.  nitrat.  (i  part  to  7  of  cosmolin). 
Jacobson  recommends  skin-grafting  for  some  cases. 

Operations  upon  Muscles  and  Tendons. 

Tenotomy  is  the  cutting  of  a  tendon.  It  may  be  open 
or  subcutaneous,  the  open  operation  being  preferred  in  dan- 
gerous regions. 

Division  of  the  Sternocleidomastoid  Muscle  for 
Wry-neck. — Subcutaneous  tenotomy  for  wry-neck  has  been 
largely  abandoned.  It  is  not  only  more  unsafe  than  the 
open  operation,  but  it  never  completely  divides  all  of  the 
contracted  band. 

The  instruments  required  consist  of  a  scalpel,  dissecting- 
forceps,  hemostatic  forceps,  scissors,  needles,  ligatures,  etc. 
The  patient  is  placed  recumbent,  the  chin  being  drawn  more 
toward  the  opposite  side. 

A  transverse  incision  is  made  over  the  muscle  about  one- 
fourth  of  an  inch  above  the  clavicle.  The  superficial  parts 
are  divided,  the  muscle  is  exposed  and  sectioned,  bleeding 
is  arrested,  and  the  skin  is  sutured.  Avoid  the  anterior 
jugular  vein,  which  is  underneath  the  muscle,  and  also  the 


SUBCUTANEOUS    TEXOTOMY.  629 

external  jugular,  which  is  close  to  the  outer  edge  of  the 
muscle.  Mikulicz  advocates  the  removal  of  almost  the 
entire  muscle,  leaving,  however,  the  upper  and  posterior 
portion  where  the  spinal  accessory  nerve  passes.  After 
operation  for  wry-neck  support  the  head  with  sand  bags 
or  a  plaster-of- Paris  dressing  until  healing  occurs,  and  then 
inaugurate  motions  active  and  passi\'e. 

Subcutaneous  Tenotomy  of  the  Tendo  Achillis. — 
This  operation  is  performed  for  club-foot,  in  which  the  heel 
is  raised.  The  tendon  is  cut  about  one  inch  above  its  point 
of  insertion.  The  instrument  used  for  the  first  puncture  is  a 
sharp  tenotome.  The  patient  lies  upon  his  back  "  with  his 
bod}' rolled  a  little  toward  the  affected  side"  (Treves),  the 
foot  being  placed  upon  its  outer  side  on  a  sand  pillow.  The 
surgeon  stands  to  the  outer  side.  The  tendon  is  rendered 
moderately  rigid,  and  the  sharp  tenotome,  with  its  blade 
turned  upward,  is  inserted  along  the  anterior  border  of  the 
tendon  until  the  surgeon's  finger  feels  the  knife  approaching 
the  outer  side.  The  sharp-pointed  instrument  is  withdrawn 
and  a  blunt-pointed  tenotome  is  inserted  in  its  place.  The 
tendon  is  drawn  into  rigidity,  and  the  surgeon  turns  the 
blade  of  his  knife  toward  the  tendon,  places  his  finger  over 
the  skin,  and  saws  toward  his  finger.  The  tendon  gi\'es  way 
with  a  snap.  Treves  states  that  a  beginner  is  apt  not  to 
push  the  knife  far  enough  toward  the  outside,  or  he  may 
in  the  first  puncture  push  the  knife  through  the  tendon;  in 
either  case  the  tendon  is  not  completely  cut.  The  little 
wound,  which  is  covered  with  a  bit  of  gauze,  Avill  be  entirely 
closed  in  forty-eight  hours.  In  club-foot  cases  after  tenotomy 
some  surgeons  at  once  correct  the  deformit}-  and  immobilize 
the  limb  in  plaster;  some  partially  correct  the  deformity  and 
apply  plaster  for  one  week,  at  which  time  they  remove  the 
plaster,  correct  the  deformity  further,  reapply  the  plaster, 
and  so  on ;  other  surgeons  do  not  attempt  correction  of  the 
deformity  until  the  cut  tendon  has  begun  to  unite,  w^hen  they 
gradually  stretch  the  new  material. 

Subcutaneous  Tenotomy  of  the  Tendon  of  the 
Tibialis  Anticus  Muscle. — The  tendon  is  divided  about 
one  and  a  half  inches  above  its  point  of  insertion.  It  can 
be  made  tense  by  extending  and  abducting  the  foot.  The 
sharp-pointed  tenotome  is  entered  upon  the  outside  of  the 
tendon,  and  is  passed  well  around  it.  The  blunt-pointed 
tenotome  is  used  to  cut  the  tense  tendon. 

Subcutaneous  Tenotomy  of  the  Tendons  of  the 
Peroneus  I/ongiis  and  Brevis  Muscles. — These  two 


630       DISEASES  AXD   INJURIES    OE  MUSCLES,    ETC. 

tendons  are  cut  together  back  of  the  external  malleolus,  and 
one  and  a  half  inches  above  the  tip  of  the  malleolus,  so  as 
to  avoid  the  synovial  sheath  (Treves).  The  patient  lies  upon 
the  sound  side,  the  outer  aspect  of  the  deformed  foot  being 
upward  and  the  inner  aspect  of  the  ankle  of  the  deformed 
side  resting  upon  a  sand  pillow.  The  instrument  is  intro- 
duced close  to  the  fibula,  and  is  carried  around  the  loose 
tendons.  A  blunt-pointed  tenotome  is  now  introduced,  its 
edge  is  turned  toward  the  tendons,  and  these  structures  are 
cut  as  they  are  made  tense. 

Subcutaneous  Tenotomy  of  the  Tendon  of  the 
Tibialis  Posticus  Muscles. — This  tendon  is  sectioned 
above  the  point  where  its  synovial  sheath  begins;  that  is, 
above  the  internal  annular  ligament  (Treves).  The  tendon  is 
made  tense  and  the  pointed  knife  is  entered  above  the  base  of 
the  inner  malleolus.  The  knife  is  entered  just  back  of  the 
inner  edge  of  the  tibia,  and  is  carried  around  the  muscle 
while  it  is  kept  close  to  the  bone.  The  tendon  is  sectioned 
with  a  blunt  knife. 

Subcutaneous  Fasciotomy  of  the  Plantar  Fascia. 
— The  contracted  bands  are  discovered  by  motions  which 
render  them  tense,  and  they  are  divided  just  in  front  of  the 
attachments  to  the  os  calcis.  The  sharp  knife  passes  between 
the  skin  and  fascia  at  the  inner  side  of  the  sole  of  the  foot. 
The  fascia  is  cut  from  without  inward  by  the  blunt-pointed 
tenotome.  It  is  usually  necessary  to  section  the  fascia  at 
more  than  one  point. 

Tendon-suture  and  Tendon -lengthening. — The  in- 
struments required  in  these  operations  are  an  Esmarch 
apparatus;  curved  needles,  and  needle-holder;  chromicized 
gut,  kangaroo-tendon,  or  silk  for  an  ordinary  case,  silver 
wire  for  a  suppurating  wound.  In  performing  tendon-suture 
make  the  part  aseptic  and  bloodless.  It  is  wise  to  apply  a 
rubber  bandage  on  the  proximal  side,  the  bandage  being 
applied  centrifugally,  forcing  the  proximal  end  of  the  tendon 
into  view  (Haegler).  If  searching  for  the  proximal  end  of 
a  flexor  of  the  finger,  flex  the  injured  finger,  and  hyper- 
extend  the  adjoining  fingers  (Filiget).  If  this  expedient 
fails,  enlarge  the  incision,  or,  what  is  better,  make  a  large 
flap  in  the  skin.  After  finding  the  ends  approximate  them, 
being  sure  the  proper  ends  are  brought  into  contact ;  stitch 
them  together  Avith  a  continuous  suture  or  with  one  of  the 
sutures  shown  in  Fig.  218,  i,  2,  and  3.  In  a  suppurating 
wound  suture  by  silver  wire  should  be  tried,  though  it  usually 
fails.     After  suturing,  remove  the  Esmarch  apparatus,  arrest 


TENDOX-SUTURE   AXD    TEXDOX-LEXGTHEXIXG.    63 1 

bleedinc-  close  the  wound  and  dress  it  antiseptically,  relax 
the  parts  and  place  the  limb  on  a  splint.  If,  after  suturing, 
there  is  '  much  tension,  stitch  the  cut  tendon  above  the 
sutures  to  an  adjacent  tendon,  and  apply  a  splint,  the  finger 


A 


L 


n 


Fig.  21 


5 Tendon-sutures  ;  i,  of  Le  Fort  ; 

2.  of  Le  Dentu ;  3,  of  Lejars. 


Fig.  219.— Anderson's  method  of  tendon- 
lengthening. 


which  was  injured  being  flexed,  the  others  being  extended 
If  onlv  the  distal  end  of  the  tendon  can  be  found,  gratt  it 
upon  the  nearest  tendon  with  a  like  anatomical  course  and 
function  When  a  tendon  has  been  sutured  begin  gentle 
massage  in  two  weeks.  Positive_  passive  motion  is  begun 
in  three  or  four  weeks.  In  old  inju- 
ries, when  the  ends  cannot  be  brought 
into  apposition,  lengthen  one  end  or 
both  ends,  either  by  the  method  of 
Anderson  (Fig.  219)  orby  the  method 
of  Czernv  (Fig.  220).     Poncet  makes 


Fig. 


-Czemv's  method  of  tendon-lengthening. 


Fig.  221. — Method  of  suturing 
the  annular  ligament  of  the 
wrist. 


several  zigzag  incisions  on  each  side  of  the  tendon,  and  when 
the  tendon  is  pulled  upon  it  elongates  decidedly.  These 
methods  of  lengthening  may  be  used  in  cases  of  deformity 
from  a  contracted  tendon.  If  the  tendon  cannot  be  lengthened 
sufficientlv,  make  a  bridge  of  catgut  from  one  end  of  it  to 
the  other,'  or  graft  in  another  tendon  from  one  of  the  lower 
animals,  or  graft  the  distal  end  to  a  tendon  of  Hke  function. 

The  annular  ligament  is  sutured  as  shown  in  Fig.  221. 

In  some  cases  in  which  a  muscle  has  been  paralyzed, 
Nicoladoni  and  others  have  divided  the  tendon  of  the  para- 
lyzed muscle  and  have  united  its  distal  end  with  the  tendon 
of  a  normal  muscle,  the  normal  tendon  being  split  to  re- 
ceive it. 


632  ORTHOPEDIC  SURGERY. 

XXI.  ORTHOPEDIC  SURGERY. 

This  branch  of  surgery  formerly  dealt  only  with  the  treat- 
ment of  deformities  by  means  of  mechanical  appliances,  but 
of  recent  years  its  domain  has  been  enlarged  to  include  the 
treatment,  surgical  and  mechanical,  of  deformities,  contract- 
ures, and  many  joint-diseases. 

Torticollis  (wry-neck)  is  a  condition  in  which  contrac- 
tion of  certain  of  the  neck-muscles  causes  an  alteration  in 
the  position  of  the  head.  The  disease  is  one-sided ;  the 
sternocleidomastoid  is  the  muscle  chiefly  involved,  though 
the  trapezius,  splenius,  and  other  muscles  sometimes  suffer. 
Acute  torticollis,  which  is  rare,  is  a  temporary  condition, 
and  results  from  cold  or  from  injury  (see  Myalgia).  Chronic 
torticollis  may  be  congenital,  may  be  due  to  nerve-irritation, 
to  an  assumed  attitude  because  of  eye-defect,  to  inflamma- 
tion of  the  glands  or  to  disease  of  the  vertebrae,  and  it  may  be 
intermittent,  but  is  usually  persistent.  The  muscle  stands 
out  in  bold  outline,  the  head  is  turned  to  the  opposite  side, 
the  ear  of  the  disordered  side  is  turned  toward  the  shoulder, 
the  chin  is  thrown  forward,  and  spinal  curvature  may  arise. 
The  corresponding  side  of  the  face  atrophies.  There  is  no 
pain.  In  many  cases  the  head  may  be  restored  to  its  nor- 
mal position  by  passive  movement  or  by  voluntary  effort,  but 
it  at  once  returns  to  its  habitual  position.  Mikulicz  asserts 
that  torticollis  is  a  chronic  fibrous  myositis,  due  often  to 
compression  during  labor.  He  further  says  that  the  lesion 
known  as  hematoma  of  the  sternomastoid,  which  occasionally 
follows  labor,  is  not  hematoma,  but  thickening  due  to 
myositis.  In  spasmodic  wry-neck  the  muscle  is  thrown  re- 
peatedly into  clonic  contractions.  In  congenital  torticollis 
the  muscle  and  the  cervical  fascia  are  shortened,  and  the  mus- 
cle does  not  relax  under  the  influence  of  an  anesthetic.  In 
torticollis  due  to  rheumatism  and  reflex  causes  the  tonic- 
ally  contracted  muscle  relaxes  when  the  patient  is  anesthe- 
tized. 

Symptoms. —  Congenital  wry-neck  is  due  to  central  ner- 
vous disease,  to  spinal  deformity,  or  to  injury  during  birth, 
and  in  this  form  the  sternomastoid  is  shortened,  hardened, 
and  atrophied.  It  may  not  be  noticed  for  some  years  be- 
cause of  the  short  neck  of  infancy.  It  is  associated  with 
a  symmetrical  development  of  the  face,  and  is  almost  inva- 
riably upon  the  right  side.  Spasmodic  wry-neck  may  present 
tonic  spasm  only,  intermittent  spasm  alone,  or  both  may 
appear  alternately.     It  is  a  disease  especially  of  adults ;  in 


DiTCVTREy'S   CONTRACTION.  633 

women  it  is  often  linked  with  hysteria.  The  exciting  cause 
may  be  a  cold,  a  blow,  or  a  mental  storm ;  the  predisposmg 
cause  is  the  neurotic  temperament.  It  may  be  due  to  enlarged 
glands,  to  carious  teeth,  or  to  eye-strain.  In  some  rare 
cases  bilateral  spasm  occurs,  the  head  being  pulled  backward 
and  the  face  being  turned  upward.  Clonic  spasms  may 
come  on  unannounced,  or  they  may  be  preceded  by  pain  and 
stiffness;  the  head  can  be  held  still  for  a  moment  only; 
there  is  sometimes  pain,  always  fatigue,  but  during  sleep  the 
contractions  cease.  The  attack  will  probably  pass  away,  but 
will  almost  certainly  recur. 

Treatment. — Congenital  wry-neck  is  treated  by  myo- 
tenotomy (through  an  open  wound)  and  the  u,se  of  proper 
braces  and  supports.  The  old  subcutaneous  myotenotomy 
should  be  abandoned,  as  aseptic  incision  enables  the  sur- 
geon to  see  and  to  feel  all  the  contracted  bands  of  fascia, 
muscle,  and  tendon,  and  to  avoid  vital  structures  (page  5  16). 
In  spasmodic  Avry-neck  treat  the  neurotic  temperament 
and  remove  any  obvious  irritation  (eye-strain,  carious  teeth, 
enlarged  glands).  In  persistent  cases  stretch  or  divide  and 
exsec't  a  part  of  the  spinal  accessory  nerve.  To  reach  this 
nerve,  make  an  incision  along  the  posterior  edge  of  the 
sternocleidomastoid  muscle,  find  the  nerve  as  it  emerges 
from  under  the  middle  of  the  muscle,  and  retract  the  mus- 
cle at  this  point  (Keen).  For  the  treatment  of  rheumatic 
wry-neck  see  Myalgia  (page  614). 

DupU3^ren's  contraction  is  a  contraction  of  the  palmar 
fascia,  of  its  digital  prolongations,  and  of  the  fibers  joining 
the  fascia  and  skin.  Fixed  contraction  of  one  or  more 
fingers  occurs.  The  ring-finger  and  the  little  finger  most 
often  suffer.  The  condition  may  be  symmetrical.  The  dis- 
ease arises  oftenest  in  men  beyond  middle  age.  The  cause 
of  this  disease  is  unknown :  some  refer  it  to  gout  or  rheu- 
matism ;  others  to  traumatism,  reflex  irritation,  or  neuritis. 
Symptoms. — Dupuytren's  contraction  is  indicated  by  a 
small  hard  lump  or  crease  which  appears  over  the  palmar 
surface  of  the  metacarpophalangeal  joint.  This  nodule 
grows  and  the  corresponding  finger  is  pulled  down.  In 
some  cases  the  tip  of  the  finger  is  forced  against  the  palm. 
The  skin  becomes  dimpled  or  puckered. 

Treatment.— In  treating  Dupuytren's  contraction  subcu- 
taneous multiple  incisions  may  be  made,  the  tense  fascia  and 
the  fasciocutaneous  fibers  being  cut.  The  finger  is  straight- 
ened and  is  placed  upon  a  straight  splint,  which  is  worn 
continuously  for  a  week  or  ten  days  and  is  worn  at  night  for 


634 


ORTIIOPEDrC  SURGERY. 


at  least  a  month.  A  more  satisfactory  operation  is  that  of 
Keen.  Keen  divides  the  skin  by  a  V-shaped  cut,  the  base  of 
the  V  being  downward,  hfts  up  the  flap,  and  dissects  out  the 
contracted  tissue. 

Syndactylism  (webbed  fingers)  is  always  congenital, 
and  may  persist  through  several  generations.  Simple  incision 
of  the  web  is  useless  ;  the  operation  to  be  performed  is  that 
of  Agnew  or  of  Diday  (Figs.  222,  223). 

In  Agnew's  operation  a  flap  of  skin  from  the  dorsum  is 
inserted  between  the  fingers  and  sutured  in  place. 

In  Diday's  operation  a  flap  is  taken  from  the  dorsal  sur- 
face and  another  flap  is  raised  from  the  palmar  surface,  and 
each  flap  is  sutured  to  the  finger  from  w^iich  it  springs. 


Fig.  222. — Agnew's  operation  for  webbed 
fingers  (Pye). 


Fig.  223. — Diday's  operation  for 
webbed  fingers  (Pye). 


Polydactylism  (supernumerary  digits)  is  always  con- 
genital, is  often  hereditar}-,  and  is  usually  symmetrical. 
There  may  be  an  incomplete  digit,  or  there  may  be  an  entire 
and  well-developed  finger  or  toe  with  a  metacarpal  or  meta- 
tarsal bone.  The  connection  to  the  metacarpus  or  metatar- 
sus may  be  by  a  fibrous  pedicle  only.  If  the  digit  is  com- 
plete, with  a  metacarpal  bone,  no  operation  is  required  ;  if  it 
is  incomplete  or  is  ill-developed,  it  should  be  removed. 

Trigger-finger  or  Jerk-finger. — The  patient  can  close 
the  fingers,  but  on  trying  to  open  them  one  finger  remains 
closed.  It  can  be  opened  by  grasping  it  with  the  other 
hand,  but  flies  open  with  a  snap  like  an  opening  knife  (Abbe). 
The  condition  is  due  to  enlargement  of  the  flexor  tendon,  or 
to  contraction  of  the  groove  in  the  transverse  ligament  in 
the  palm  (Tubby).  This  condition  may  be  due  to  a  ganglion, 
enchondroma,  or  tenosynovitis. 

Treatment. — Ifa  trauma,  a  ganglion,  or  inflammation  exists, 
treat  by  ordinary  means.  If  there  is  no  obvious  cause,  put  a 
compress  over  the  tunnel  in  the  ligament  and  apply  a  splint. 

Mallet-finger. — This  is  called  also  drop-finger  and  rupt- 
ure of  the  extensor  tendon.  It  is  due  to  a  blow  in  the  direc- 
tion of  flexion  when  the  finger  is  extended.     It  is  supposed  to 


GENU   VARUM. 


be  due  partly  to  stretching  and  partl\'  to  rupture  of  the  ex- 
tensor tendon  at  the  point  at  which  it  is  the  posterior  Hga- 
ment  of  the  distal  interphalangeal  joint.  Abbe  has  shown 
that  baseball-players  are  liable  to  a  condition  which  is  the 
reverse  of  this,  in  which  the  last  phalanx  is  dislocated  back- 
ward. Drop-finger  is  treated  by  incision  and  suture  of  the 
tendon  to  the  periosteum  (Abbe). 

Genu  valgum  (knock-knee)  results  from  an  unnatural 
growth  of  the  internal  condyle,  causing  the  shaft  of  the 
femur  to  curve  inward  and  the  internal  lateral  ligament  of 
the  knee-joint  to  stretch,  the  knees  coming  close  together 
and  the  feet  being  wideh^  separated.  This  deformity  is  usu- 
ally noted  when  the  child  begins  to  walk,  but  it  may  not 
appear  until  puberty  or  even  long  after.  Knock-knee  may 
arise  from  rickets,  from  an  occupation  demanding  prolonged 
standing,  or  from  flat-foot.  It  may  occur  in  one  knee  or 
in  both  knees. 

Treatment. — Mild  rachitic  cases  of  knock-knee  ma}-  re- 
main in  slight  deformity,  or  may  get  w^ell  from  improvement 
of  the  general  health.  In  ordinary  cases  simply  treat  the 
ricket}'-  condition.  The  patient  is  forbidden  to  stand  or  to 
walk,  and  the  limb,  after  being  put  as  straight  as  can  be, 
is  fixed  on  an  external  splint  and  a  pad  is  put  over  the 
inner  condyle.  Later  in  the  case  plaster  of  Paris  is  used. 
Some  surgeons  prefer  to  immobilize  while  the  leg  is  flexed 
to  a  right  angle  with  the  thigh.  In  a  severe  case  the  sur- 
geon can  immobilize  after  forcibly  straightening  (causing  an 
epiphyseal  separation)  or  after  the  performance  of  osteotomy 
(Fig.  193).  Osteotomy  is  preferable  to  fracture  by  a  mechan- 
ical appliance  (osteoclasis). 

Genu  varum  (bow-legs)  is  the  opposite  of  knock-knee. 
Usually  both  legs  are  bowed 
out,  the  knees  being  widely 
separated,  the  tibise  and  fe- 
murs, as  a  rule,  being  curved, 
and  the  feet  being  turned  in. 
This  disease  in  early  life  is  due 
to  rickets,  the  weight  of  the 
body  producing  the  deformity. 
In  older  people  incurable  bow- 
legs may  arise  from  arthritis 
deformans. 

Treatment.  —  Some        mild 
cases   of  genu 


Fig.  224.  —  Talipes 
equinus  (Albert). 


varum   recover 
as  a  result  of  improvement  in  the  health 


Fig.  225. — Talipes  cal- 
caneus (Albert). 


Ordinarv  cases 


635 


OR  THOTEDIC  SUR  GER  Y. 


are  treated  by  braces,  by  plaster-of-Paris  bandages,  and  by 
attention  to  the  general  health.  When  the  bones  have  hard- 
ened osteotomy  is  necessary. 

Club-hand. — A  congenital  deformity  in  which  the  hand 
deviates  from  the  normal  relation  to  the  forearm.  It  is  usually 
associated  with  other  deformities.  In  some  cases  the  radius 
and  possibly  some  of  the  carpal  bones  are  absent. 

Treatment. — By  massage  and  passive  motion,  by  immo- 
bilization, by  tenotomy  or  osteotomy. 

Talipes  (club-foot)  is  a  permanent  deviation  of  the  foot. 
There  are  several  forms.  Talipes  cqidmis  (Fig.  224)  is  a  con- 
firmed extension  ;  talipes  calcaneus  (Fig.  225)  is  a  confirmed 
flexion  ;  talipes  varus  is  a  confirmed  adduction  and  inversion  ; 
and  talipes  valgus  is  a  confirmed  abduction  and  eversion.  Two 
of  these  forms  may  be  combined,  as  in  talipes  equino-varus 
(Fig.  226),  talipes  equino-valgus,  talipes  calcaneo-varus,  and 
talipes  calcaneo-valgus.  The  causes  of  talipes  are  con- 
genital or  acquired.  The 
congenital  form  is  due 
to  persistence  of  the 
fetal  form  of  the  foot. 
Acquired  cases  may 
arise  from  infantile  par- 
alysis, from  spastic  con- 
tractions, from  cica- 
trices, from  traumatisms, 
from  arrest  of  bony 
growth  following  upon 
the  inflammation  of 
bone,    or    from    hysterical    contractures. 

Talipes  equinus  is  rarely  congenital.  In  this  condition  the 
patient  walks  upon  the  toes  and  cannot  bring  the  heel  to 
the  ground. 

Talipes  Calcaneus. — The  patient  walks  upon  the  heel  and 
cannot  bring  the  toes  to  the  ground.  The  true  form  is  seen 
in  congenital  cases,  the  flexors  of  the  foot  being  shortened, 
and  the  tendo  Achillis  being  lengthened. 

Talipes  varus  is  rarely  met  with  without  equinus.  In  this 
condition  the  patient  walks  on  the  outer  edge  of  the  foot. 

Talipes  valgus  is  met  with  in  flat-foot.  The  patient  walks 
on  the  inner  edge  of  the  foot. 

Talipes  equino-varus. — The  heel  is  raised  and  the  patient 
walks  upon  the  outer  edge  of  the  foot.  This  is  the  usual 
congenital  form. 

Talipes  equino-valgus  is  very  rarely  congenital.     The  heel 


Fig.  226. — Double   equino-varus    {Am.    Text-book 
of  Surgery) . 


PES   PLAXUS.  637 

is  raised  and  the  patient  walks  upon  the  inner  side  of  the 
foot. 

Talipes  calcaiico-vanis  is  a  combination  of  calcaneus  and 
varus. 

Talipes  calcaiico-valgiis  is  a  combination  of  calcaneus  and 
valgus. 

Treatment. — In  congenital  cases  the  condition  is  usually 
manifest  on  both  sides,  and  is  nearly  ahva\'s  talipes  equino- 
varus.  Congenital  club-foot  should  be  treated  in  infancy, 
and  when  a  restoration  to  position  can  be  effected  by  the 
hands  of  the  surgeon,  is  treated  by  plaster-of-Paris  bandages. 
If  a  child  has  begun  to  walk,  it  may  still  be  possible  to 
correct  the  deformity  eventually  by  manipulations,  by 
plaster-of-Paris  bandages,  or  by  club-foot  shoes,  but  most 
cases  require  tenotomy  of  the  tendo  Achillis  before  the 
application  of  the  shoe  or  the  plaster.  The  club-foot  shoe 
may  do  good  service,  but  in  many  instances  it  is  painful  and 
is  not  so  efficient  as  plaster  of  Paris.  In  severe  cases,  before 
applying  the  plaster,  the  patient  is  given  ether ;  the  surgeon 
cuts  the  tendo  Achillis,  the  tendons  of  the  anterior  and  pos- 
terior tibial  muscles,  and  the  plantar  fascia,  and  forcibly  cor- 
rects the  deformity.  In  old  cases  with  alteration  in  the  shape 
of  the  bones,  cuneiform  osteotomy,  or  the  removal  of  the 
cuboid  or  other  tarsal  bones,  may  be  indicated.  In  these 
cases  Phelps  advises  an  open  transverse  division  of  all  rigid 
plantar  soft  parts.  Buchanan  employs  subcutaneous  division 
of  all  resistant  structures.  In  some  cases  of  talipes  calca- 
neus the  surgeon  may  be  forced  to  shorten  the  tendo  Achil- 
lis. In  talipes  due  to  infantile  paralysis  the  operative  treat- 
ment is  the  same,  but  we  should  not  immobilize  in  plaster, 
but  rather  in  some  apparatus  which  can  easily  be  removed  to 
permit  the  use  of  massage  and  electricity.  In  parah^tic  cases 
Nicoladoni's  operation  is  occasionally  employed.  This  con- 
sists in  dividing  the  tendon  of  the  paralyzed  muscle  and 
attaching  its  distal  end  to  the  adjacent  tendon  of  a  healthy 
muscle.  (For  full  consideration,  see  a  work  on  Orthopedic 
Surger}'.) 

Pes  planus  (flat-foot)  is  a  condition  in  which  there  is 
loss  of  the  arch  of  the  foot  due  to  muscular  parah'sis  or  liga- 
mentous weakness,  to  prolonged  standing,  or  to  trauma. 
Flat-foot  is  especially  apt  to  occur  in  rickets.  Spurious  flat- 
foot,  or  inflammator}'  flat-foot,  occurs  in  Pott's  fracture,  and 
in  inflammation  of  the  ankle-joint  or  the  tendon  of  the  pero- 
neus  longus.  Paralytic  flat-foot  is  seen  after  infantile  paral- 
ysis.    Static  flat-foot  is  due  to  "  lack  of  balance  between  the 


638  ORTHOPEDIC  SURGERY. 

weight  of  the  body  and  the  length  of  the  foot"  (Moore). 
All  children  are  born  with  pronated  feet,  but  the  arch  usually 
begins  to  form  soon  after  birth ;  in  some  cases  it  never 
forms.  Pes  planus  is  productive  of  much  pain  upon  stand- 
ing or  walking;  in  fact,  the  individual  may  be  completely 
crippled.  Pain  is  quickly  relieved  upon 
'         -.  :?  sitting  down.    Walking  upon  the   toes  is 

o  "o       V   !l  {?)        not  painful.     Flat-foot  can  at  once  be  rec- 
C  -^M  '^^^     ognized  by  wetting  the  sole  of  the  patient's 

\7"  ^j     ■"^■-       I     foot  with  a  colored  fluid  and  causing  him 
t    "I    \  j     to  step  firmly  upon  a  piece  of  paper  (Fig. 

)  /      t->'.'    1'       227,  A,  b).     It  can    also    be    detected   by 
J       V  .;    \       measurement  to   find   the    middle   of   the 
<■,      ^      foot.     In  flat-foot  the  extremity  is  length- 
4^        ened.     Golding-Bird    points   out  that   the 

Fig.   227. — Print   of  a  •in  r      i         r  -i  •  r  ■        1 

normal  foot-sole  (a)  middle  ol  the  loot  IS  the  pomt  01  articula- 
\b)  (Albert)!^'  oot-so  e  ^j^^^  ^^  ^j^^  inner  cuneiform  and  the  meta- 
tarsal bone  of  the  great  toe.  In  flat-foot 
the  greatest  change  is  in  the  posterior  half  of  this  line.  The 
extent  to  which  the  posterior  measurement  exceeds  the 
anterior  is  the  degree  of  flat-foot.  The  excess  may  reach 
three-fourths  of  an  inch. 

Treatment. — In  static  flat-foot  rest  in  bed  is  employed  for 
two  weeks,  and  then  exercise  is  practised  several  hours  a 
day  to  increase  the  arch.  Rising  upon  the  toes  again  and 
again  is  valuable.  After  exercise  the  patient  rests  for  a  time, 
sitting  tailor-fashion  with  legs  crossed  under  him.  Massage 
is  valuable.  A  shoe  should  be  made  containing  a  piece  of 
steel  so  arranged  as  to  raise  the  arch  of  the  foot.  The 
patient's  general  health  must  also  be  attended  to.  In  very 
severe  cases,  with  fixation  and  bone  formation,  operation 
may  be  required.  Gleich  shortens  the  foot  and  raises  the 
arch  by  sawing  through  the  os  calcis  and  fastening  the  pos- 
terior part  of  this  bone  at  a  lower  level.  Trendelenburg 
advises  supramalleolar  osteotomy.  This  operation  permits 
of  adduction,  and  the  adducted  foot  should  be  put  up  in  an 
immovable  dressing  of  plaster  of  Paris.  Ogston  resects  the 
astragaloscaphoid  joint;  Golding-Bird  and  Davy  remove  the 
scaphoid  bone ;  Stokes  removes  a  wedge-shaped  piece  from 
the  head  and  neck  of  the  astragalus.  In  paralytic  flat-foot, 
which  arises  from  infantile  paralysis,  employ  exercise,  elec- 
tricity, and  massage. 

Pes  cavUS  (hollow-foot)  is  an  increase  in  the  arch  of 
the  foot,  due  to  contraction  of  the  peroneus  longus  muscle 


ME  r.l  TA RSA L  GIA.  639 

or  to  parah'sis  of  the  muscles  of  the  calf     It  is  the  opposite 
of  flat-foot. 

Treatment. — A  shoe  is  worn  containing  a  plate  of  steel  in 
the  sole,  and  pressure  is  applied  over  the  instep.  Tenotomy, 
division  of  the  plantar  fascia,  or  excision  of  bone  may  be 
required.  In  paralytic  cases  apply  electricity  and  massage 
to  the  parah'zed  muscles. 

Hallux  valgus,  or  varus,  a  displacement  of  the  great 
toe  outward  or  inward,  may  occur  in  the  young,  but  it  is 
most  frequent  in  old  men.  It  arises  often  from  wearing 
narrow  shoes,  but  may  be  due  to  gout  or  to  rheumatic  gout. 
In  hallux  valgus  a  bunion  is  apt  to  form  o\'er  the  metatarso- 
phalangeal joint. 

Treatment. — An  arrangement  may  be  worn  to  straighten 
the  toe  and  to  protect  the  bunion  (Fig.  217),  osteotom\'  may 
be  performed  upon  the  metatarsal  bone,  the  joint  ma)'  be 
excised,  or  amputation  may  be  required. 

Hammer-toe  (Fig.  228)  is  a  condition  in  which  there  is 
flexion  of  one  or  more  toes  at  the  first  interphalangeal  joint. 
Shattuck  shows  that  this  condition  is  due  to 
contraction  of  "the  plantar  fibers  of  the  lateral 
ligaments  of  the  joint."  ^  This  disease  usually 
begins  in  youth.  A  bunion  is  apt  to  form, 
and  the  joint  may  become  dislocated. 

Treatment. — Terrier's  plan  of  treatment  Fig.  228.— Ham- 
consists  in  making  a  dorsal  flap,  removing  a 
bursa  if  one  is  found,  dividing  the  extensor  tendon,  opening 
the  articulation,  removing  each  articular  surface  with  cut- 
ting-forceps, suturing  the  soft  parts,  and  apph'ing  a  plantar 
splint  for  two  weeks. ^  Some  surgeons  excise  the  joint. 
Probably  amputation  of  the  toe  is  the  best  treatment. 

Metatarsalgia  (Morton's  Disease). — This  disease  was 
first  described  by  Dr.  Thomas  G.  Morton  of  Philadelphia,  in 
1876.  It  is  a  painful  condition  of  the  foot,  due  to  jamming 
of  a  nerve  between  the  heads  of  the  fourth  and  fifth  meta- 
tarsal bones.  The  head  of  the  fifth  metatarsal  bone  is,  by 
lateral  pressure,  forced  against  and  below  the  neck  of  the 
fourth  metatarsal,  and  as  a  result  the  superficial  branch  of 
the  external  plantar  nerve  and  its  two  digital  branches  are 
squeezed.  It  is  usually  associated  with  flat-foot.  Pain  is 
produced  by  walking,  and  the  suffering  may  be  so  severe  that 
the  patient  is  obliged  to  sit  down  at  once.  When  the  shoe  is 
removed  and  the  foot  is  rested  the  pain  soon  abates.  The 
pain  is  felt  on  the  outer  and  inner  sides  of  the  little  toe,  the 

1  American   Text-book  of  Surgery.  -'  Revue  de  Chiritrgie,  July,  1895. 


640  ORTHOPEDIC  SURGERY. 

outer  side  of  the  fourth  toe,  and  about  the  head  of  the  fifth 
and  the  neck  of  the  fourth  metatarsal  bones.  Pain  can  be 
developed  by  grasping  the  foot  in  the  hand  and  squeezing 
it.     If  flat-foot  exists,  there  is  also  pain  due  to  this  trouble. 

Treatment. — Mild  cases  may  be  cured  occasionally  by 
wearing  well-fitting  shoes  and  employing  massage.  Some 
cases  require  a  brace.  Severe  cases  demand  resection  of 
the  fourth  metatarsophalangeal  joint,  or  amputation  of  the 
fourth  toe,  and  with  it  the  head  of  the  fourth  metatarsal 
bone. .  Graham  of  Washington  has  cured  cases  by  excis- 
ing a  portion  of  the  superficial  branch  of  the  external  plan- 
tar nerve. 

Coxa  vara  is  a  disease  characterized  by  bending  of  the 
neck  of  the  femur,  the  hip-joint  being  perfectly  healthy,  and 
the  condition,  as  a  rule,  being  unilateral.  This  condition 
was  described  by  Miiller  in  1889.  Coxa  vara  begins,  as  a 
rule,  between  the  thirteenth  and  twentieth  years,  and  the 
commonly  accepted  view  has  been  that  the  deformity  is 
rachitic,  but  Kredel  has  reported  two  congenital  cases.^ 
The  patient  develops  a  limp,  and  grows  tired  after  slight  ex- 
ertion, but  there  is  no  swelling  nor  tenderness,  and  little  or 
no  pain.  Shortening  after  a  time  becomes  apparent,  and 
the  trochanter  can  be  detected  above  Nelaton's  line.  The 
extremity  is  adducted.     The  .r-rays  show  the  deformed  bone. 

Treatment. — As  long  as  bending  is  progressing  employ 
rest.  When  the  bone  hardens  perform  osteotomy  below  the 
trochanters. 

Flail-joints. — After  an  attack  of  infantile  paralysis  in- 
volving the  entire  lower  extremity  of  each  side,  the  limbs 
become  limp  and  swing  flail-like  when  the  extremity  is  made 
to  move,  and  the  joints  are  much  relaxed.  In  such  cases 
the  psoas  and  iliacus  muscles  are  never  completely  par- 
alyzed, and  the  aim  of  the  surgeon  is  to  utilize  these  mus- 
cles in  enabling  the  patient  to  walk.  In  many  cases  the 
application  of  apparatus  is  sufficient.  In  others  ankylosis 
may  be  established  in  the  ankles  and  knees  by  operation. 
If  ankylosis  is  established  in  these  joints,  the  psoas  and  iliacus 
muscles  become  able  to  move  the  legs. 

1  Centralbl.  f.  Chir.,  Oct,  17,  1896. 


XEl'RALGIA.  641 

XXII.  DISEASES  AND  INJURIES  OF  NERVES. 

I.  Diseases  of  Nerves. 

Neuritis,  or  inflammation  of  a  nerve,  may  be  limited 
or  be  widely  distributed  (multiple  neuritis).  The  first-men- 
tioned form  will  here  be  considered.  The  causes  of  neuritis 
are  traumatism,  wounds,  over-action  of  muscles,  gout,  rheu- 
matism, syphilis,  fevers,  and  alcoholism. 

Symptoms. — The  symptoms  of  neuritis  are  as  follows  : 
excessive  pain,  usually  intermittent,  in  the  area  of  nerve- 
distribution.  The  pain  is  worse  at  night,  is  aggravated  bv 
motion  and  pressure,  and  occasionally  diffuses  to  adjacent 
nerve-areas  or  awakens  sympathetic  pains  in  the  opposite 
side  of  the  body.  The  nerve  is  very  tender.  The  area  of 
nerve-distribution  feels  numb  and  is  often  swollen.  Earl\- 
in  the  case  the  skin  is  h\-peresthetic  ;  later  it  ma}-  become 
anesthetic.  The  muscles  atrophy  and  present  the  reactions 
of  degeneration  ;  that  is,  the  muscles  first  cease  to  respond 
to  a  /7z//V//r-interrupted,  and  next  to  a  i'/c^tt'/j'-interrupted,  fara- 
dic  current ;  faradic  excitabilit}'  diminishes,  but  galvanic  ex- 
citability increases.  When,  in  neuritis,  faradism  produces  no 
contraction,  a  slowh'-interrupted  galvanic  current  Avhich  is 
so  weak  that  it  would  produce  no  movement  in  the  health}^ 
muscle  causes  marked  response  in  the  degenerated  muscle. 
In  health  the  most  vigorous  contraction  is  obtained  by  clos- 
ing with  the  —  pole ;  in  degenerated  muscles  the  most 
vigorous  contraction  is  obtained  by  closing  with  the  --  pole. 
When  voluntary  power  returns  gah^anic  excitabilit}'  declines, 
but  power  is  often  nearly  restored  before  faradic  excitability 
becomes  manifest  (Buzzard). 

Treatment. — The  treatment  of  neuritis  consists  of  rest  upon 
splints,  and  the  use  of  an  ice-bag  earh-  in  the  case  and  a  hot- 
water  bag  later.  Blisters  over  the  course  of  the  nerv^e  are  of 
value,  especially  in  traumatic  neuritis.  Massage  and  electric- 
it}'  must  be  used  to  antagonize  degeneration.  A  descending 
galvanic  current  allays  pain  to  some  extent.  Deep  injections 
of  chloroform  ma}'  alia}-  pain.  Treat  the  patient's  general 
health,  especialh^  any  constitutional  disease  or  causativ^e 
diathesis.  The  salicylate  of  ammonium  or  phenacetin  ma}'- 
be  given  internalh'.  In  some  cases  nerve-stretching  is  ad- 
visable. 

Neuralgia  is  manifested  b}-  \-iolent  paroxysmal  pain  in 
the  trajectory  of  a  nerve.  This  disease,  unless  it  is  exces- 
sivel}^  severe  and  persistent,  is  treated,  as  a  rule,  b}^  the  physi- 
cian.    Neuralgia  of  stumps  and  scars  is  a  surgical  condition, 

41 


642  DISEASES  AND   INJURIES    OF  NERVES. 

and  is  due  to  neuromata,  or  entanglement  of  nerve-fila- 
ments in  a  cicatrix.  Tic  douloureux  and  other  intractable 
neuralgias  require  careful  removal  of  any  cause  of  reflex 
irritation  (stomach,  eyes,  uterus,  nose,  throat,  etc.).  Tic 
douloureux  has  been  treated  by  removal  of  the  Gasserian 
ganglion ;  removal  of  Meckel's  ganglion  ;  ligation  of  the 
common  carotid  artery;  neurectomy  of  terminal  branches  of 
the  fifth  nerve ;  division  of  motor  nerves ;  massive  doses  of 
strychnin  (Dana)  and  purgatives  (Esmarch). 

Treatment  of  Neuralgia  of  Stumps. — Excise  the  scar ; 
find  the  bulbous  end  of  the  nerve  and  cut  it  off.  Senn  tells 
us  to  section  the  nerve  by  V-shaped  cuts,  the  apex  of  the  V 
being  toward  the  body,  and  to  suture  the  flaps  together. 
Senn's  method  will  prevent  recurrence.  In  some  cases  re- 
amputation  is  performed.  In  entanglement  of  a  nerve  in 
a  scar  remove  a  portion  of  a  nerve  above  the  scar. 

2.  Wounds  and  Injuries  of  Nerves. 

Section  of  Nerves  (as  from  an  incised  wound). — After 
nerve-section  the  entire  peripheral  portion  of  the  nerve 
degenerates  and  ceases  structurally  to  be  a  nerve  in  a  few 
weeks,  but  after  many  months,  or  even  years,  the  nerve 
may  regenerate — with  difificulty,  if  union  of  the  ends  has 
not  taken  place,  with  much  greater  ease  if  the  ends  have 
united.  The  proximal  end  degenerates  only  in  the  portion 
immediately  adjacent  to  the  section ;  it  rapidly  regen- 
erates, and  a  bulb  or  enlargement  composed  of  fibrous 
tissue  and  small  nerve-fibers  forms  just  above  the  line  of 
section  ;  this  bulb  adheres  to  the  perineural  tissues.  Union 
of  a  divided  nerve  is  brought  about  by  the  projection  of  an 
axis-cylinder  from  the  proximal  end  or  from  each  end  and 
the  fusion  of  these  cylinders.  The  nearer  the  two  ends  are  to 
each  other  the  better  the  chance  of  union. 

Symptonis. — Pi'onounced  changes  occur  in  the  trajectory 
of  a  divided  nerve.  The  muscles  degenerate,  atrophy  and 
shorten,  and  develop  the  reactions  of  degeneration.  When 
union  of  the  nerve  occurs  the  muscles  are  restored  to  a 
normal  condition.  If  the  nerve  contains  sensory  fibers,  com- 
plete anesthesia  (to  touch,  pain,  and  temperature)  usually 
follows  its  division  ;  but  if  a  part  is  supplied  by  another  nerve 
as  well  as  by  the  divided  one,  anesthesia  will  not  be  com- 
plete. Trophic  changes  arise  in  the  paralyzed  parts.  Among 
these  changes  are  muscular  atrophy  ;  glossy  skin  ;  cutaneous 
eruptions;  ulcers;  dry  gangrene;  painless  felons;  falling  of  the 


SECTION   OF  NERVES.  643 

hair;  brittleness,  furrowing  or  casting  off  of  the  nails  ;  joint- 
inflammations;  and  ankylosis.  Immediately  after  nerve-sec- 
tion vasomotor  paralysis  comes  on,  and  for  a  few  days  the 
paralyzed  part  presents  a  temperature  higher  than  normal. 
The  diagnosis  as  to  which  nerve  is  cut  depends  upon  a  study 
of  the  distribution  of  paralysis  and  anesthesia.^ 

Treatment. — In  all   recent  cases   of  nerve-section,  suture 
the  ends   of  the   divided   nerve.      In    123  cases  of  primary 
suture,  1 19  were  cured  in  from  one  day  to  one  year  (Wil- 
lard).  'in    130  cases  of  secondary  suture,  80  per  cent,  were 
more  or  less  improved  (Willard).     The  return  of  sensation 
may  be    rapid    or    may  be    slow ;    muscular    power  returns 
more    slowly  than    sensation.     If  the  patient    is    not    seen 
until    long    after    the    accident,  incise    and    apply  sutures 
(secondary  sutures) ;  if  the  nerve  cannot  be  found,  extend 
the  incision,  find  the  trunk  above    and  trace    it  down,  and 
find   the  trunk  below  and  follow  it  up.     Even  after  primary 
suture    loss    of    function    is    bound    to    occur   for    a    time. 
After  secondary  suture  sensation  may  return  in  a  few  days, 
but  it  may  not  return  until  after  a  much   longer  period ;  in 
any    case    muscular    function    is    not    restored  for  months. 
After  partial  section  of  a  nerve  the  ends  should  be  sutured. 
In  performing  secondary  suture  it  may  be  necessary  to  effect 
"  lengthening  "  in  order  to  approximate  the    ends.     Trans- 
plantlition    of  a   portion  of  nerve    is    sometimes   practised. 
Transplantation  is   bridging  the  gap  by  means  of  a  portion 
of  nerve  from  one  of  the  lower  animals   or  from  a  recently 
amputated  human  limb.     Nerve  transplantation  may  fail  ut- 
terly, it  may  be  followed  by  great  improvement;  but  absolute 
and  perfect  restoration  of  function  cannot  be  obtained.     R. 
Peterson  -  has  made  a  study  of  the  20  recorded  cases  of  nerve 
transplantation.     Eight  of  the  operations  were  primary,  and 
12  were  secondary.     The  periods  after  the  injury  at  which 
operation  was  performed  varied  from  forty-eight  hours  to  a 
year  and  a  quarter.     Four  of  the  8  primary  cases  improved. 
Eight  of  the  12  cases  of  secondary  operation  showed  improve- 
meiit  in    motion  or  sensation.     The    distance    between  the 
nerves  did  not  seem  to  affect  the  results.     No  case  recovered 
completely,  but  in  one  case  sensation  returned  completely 
and  only  the  abductors  of  the  thumb  remained  w^eak.     In 
most   cases  benefited  sensation  returned  by  the  tenth  day 
and  motion  in  two  and  a  half  months.     In  one  of  the  suc- 

1  See  Bowlby  on  Injuries  of  Nerves. 
'^  Am.  Jour.  Med.  Sciences,  April,  1899. 


644  DISEASES  AND   INJURIES    OF  NERVES.    ■ 

cessful  cases,  that  of  Mayo  Robson/  the  spinal  cord  of  a 
rabbit  was  used. 

Pressure  upon  nerves  may  arise  from  callus,  scars, 
a  dislocated  bone,  a  tumor,  or  pressure  from  an  external 
body. 

The  symptoms  may  be  anesthetic,  paralytic,  or  trophic. 

The  treatment  is  as  follows :  remove  the  cause  (reduce  a 
dislocated  bone,  chisel  away  callus,  excise  a  scar,  etc.) ;  then 
employ  massage,  douches,  exercise,  and  electricity. 

Dislocation  of  the  Ulnar  Nerve  at  the  Elbovr. — 
This  condition  is  very  rare.  It  may  occur  as  a  complication 
of  a  fracture  or  a  dislocation,  or  as  an  uncomplicated  condi- 
tion. It  may  be  produced  by  violence  or  by  muscular  effort, 
which  ruptures  the  fascia  the  function  of  which  is  to  retain 
the  nerve  back  of  the  inner  condyle  of  the  humerus.  In  some 
cases  the  symptoms  are  slight  and  transitory,  the  nerve  func- 
tionating well  in  its  new  situation.  As  a  rule,  there  are  pain, 
numbness,  or  anesthesia  of  the  ulnar  trajectory,  some  stiff- 
ness of  the  elbow,  and  stiffness  of  the  little  finger  and  ring  fin- 
ger. The  nerve  can  be  felt  in  front  of  the  inner  condyle  of 
the  humerus.  In  some  cases  neuritis  follows,  with  trophic 
changes. 

Treatment. — Mccormick's  Operation. — Expose  the  nerve 
by  an  incision,  incise  the  fibrous  tissue  back  of  the  inner 
condyle,  and  press  the  nerve  into  the  bed  prepared  for  it  and 
hold  it  in  place  by  sutures  of  kangaroo-tendon  passing 
through  the  triceps  tendon.  Wharton  advises  suturing  also 
"  the  margin  of  the  fascial  expansion  of  the  triceps  tendon 
superficial  to  the  nerve.^ 

Contusion  of  Nerves. — The  symptoms  of  contusion  of 
nerves  may  be  identical  with  those  of  section.  Sensation  or 
motion,  or  both,  may  be  lost.  The  case  may  recover  in  a 
short  time,  or  the  nerve  may  degenerate  as  after  section. 

The  treatment  at  first  is  rest,  and  later  electricity,  massage, 
frictions,  and  douches. 

Punctured  Wounds  of  Nerves. — The  symptoms  of 
punctured  wounds  of  nerves  may  be  partly  irritative  (hyper- 
esthesia, acute  pain,  and  muscular  spasm)  and  partly  paralytic 
(anesthesia,  muscular  wasting,  and  paralysis). 

The  treatment  after  the  puncture  has  healed  is  the  same 
as  that  for  contusion. 

1  Am.  Jour.  Med.  Sciences,  April,  1899. 

'•^  A  report  of  fourteen  cases  of  dislocation  of  the  ulnar  nerve  at  the  elbow, 
by  H.  R.  Wharton,  Avi.  Jour.  Med.  Sciences,  Oct.,  1895. 


NEURORRHAPHY,    OR   A'ERVE-SUTCRE.  645 

3.  Operations  upon  Nerves. 

Neurorrhaphy,  or  Nerve-suture. — When  a  nerve  is 
completeh'  or  partial!}'  divided  by  accident  it  should  be 
sutured.  The  instruments  required  are  an  Esmarch  ap- 
paratus, a  scalpel,  blunt  hooks,  dissecting-forceps,  hemo- 
static forceps,  curved  needles  or  sewing-needles,  a  needle- 
holder,  and  catgut,  silk,  or  kangaroo-tendon.  In  primary' 
suture  render  the  part  bloodless  and  aseptic.  Enlarge  the  in- 
cision if  necessary.  If  the  ends  can  readily  be  approximated, 
pass  two  or  three  sutures  through  both  the  nerve  and  its 
sheath  and  tie  them  (Fig.  229).  If  the  ends 
cannot  be  approximated,  stretch  each  end 
and  then  suture.  Remove  the  Esmarch 
band,  arrest  bleeding,  suture  the  wound, 
dress  antisepticallv,  and  put  the  part  in      ^  ^         . 

r^  '   '  ^  A  r  rlG.  229. — iNerve-suture. 

a  relaxed  position  on  a  splmt.  After 
union  of  the  wound  remove  the  .splint  and  use  massage, 
frictions,  electricity,  and  the  douche.  The  operation  in  some 
instances  fails,  but  in  many  cases  succeeds.  In  some  few 
cases  sensation  returns  in  a  few  days,  but  in  most  cases  does 
not  return  for  many  weeks  or  months.  Sensation  is  restored 
before  motor  power.  Secondary  suture  is  performed  upon 
cases  long  after  division  of  a  nerve.  The  part  is  rendered 
aseptic  and  bloodless ;  an  incision  is  made ;  the  bulbous 
proximal  end  is  easily  found  and  loosened  from  its  adhesions  ; 
the  shrunken  distal  end  is  sought  for  and  loosened  (it  may 
be  necessary  to  expose  the  nerve  below  the  wound  and  trace 
its  trunk  upward)  ;  the  entire  bulb  of  the  proximal  end  is 
cut  off;  about  one-quarter  of  an  inch  of  the  distal  end  is  re- 
moved (Keen) ;  each  end  is  stretched, 

and    the    ends    are    approximated  ^ ^      ^ 

and  sutured  together.  If  stretching 
does  not  permit  of  approximation, 
adopt  one  of  Bowlby's  expedients 
(Fig.  230),  or  graft  a  bit  of  nerv^e 


from  a  recently  amputated  limb  or        „  c  ,       ,-    „,^.  k  . 

-'_  y  ^  _  Fig.  230. — Suture  01    a  nerve  b^ 

from  a  lower  animal  (it  makes  no  dif-         splitting  the  ends  (Beach), 
■ference    as  to  whether  the    grafted 

nerve  were  motor,  sensory,  or  mixed).  Mayo  Robson  has 
succeeded  in  grafting  the  spinal  cord  of  a  rabbit  in  the 
median  nerv^e  of  a  man.  The  restoration  of  function  was 
almost  complete.  Allis  suggested  shortening  the  limb  by 
excising  a  piece  of  bone,  and  the  operation  has  been  carried 
out    successfully   by  Keen,   Rose,   and   others.     Letievant 


646  DISEASES  AND   INJURIES    OF  NERVES. 

attaches  the  cut  end  of  the  peripheral  portion  of  a  divided 
nerve  to  an  adjacent  uncut  nerve.  Assaky  uses  the  suture 
a  distance,  composed  of  catgut  passing  from  end  to  end  and 
serving  as  a  bridge  for  reparative  material. 

Neurectasy,  Neurotomy,  and  Neurectomy. — Neurec- 
tasy, or  nerve-stretching,  may  be  applied  to  motor,  sensory,  or 
mixed  nerves.  A  nerve  can  be  stretched  about  one-twentieth 
of  its  length  (Vogt).  Neurectasy  has  been  employed  for  neu- 
ralgia, neuritis,  muscular  spasm,  hyperesthesia,  anesthesia, 
painful  ulcer,  perforating  ulcer,  and  the  pains  of  locomotor 
ataxia.  The  operation,  which  was  once  the  fashion,  seems  to 
benefit  some  cases,  but  it  is  not  now  thought  so  highly  of  as 
formerly.  The  incision  for  neurectasy  is  identical  with  the 
incision  for  neurectomy  or  neurotomy  of  the  same  nerve. 
Neurotomy,  or  section  of  a  nerve,  is  only  performed  upon 
small  and  purely  sensory  nerves.  It  is  perfoi'med  chiefly  for 
peripheral  neuralgia  or  for  some  other  painful  malady.  It  is 
useless,  because  sensation  soon  returns.  Paget  saw  complete 
return  of  sensation  in  four  weeks  after  division  of  the  median 
nerve.  Corning  endeavors  to  prevent  this  regeneration  by 
inserting  oil  between  the  ends.  He  uses  oil  of  theobroma 
containing  enough  paraffin  to  make  the  melting-point  io5°F. 
The  oil  is  melted,  is  injected  around  the  nerve,  and  cold  is 
applied.  The  nerve  is  now  sectioned  with  a  canaliculated 
knife,  the  ends  are  separated  widely,  more  oil  is  injected,  and 
cold  is  again  applied.  The  theory  is  that  this  oil,  which  is 
solid  at  the  temperature  of  the  body,  devitalizes  the  nerve  at 
the  point  of  section  and  acts  as  a  barrier  to  the  passage  of  re- 
generating fibers.  This  method  has  been  applied  especially  in 
cervicobrachial  neuralgia.^  Netirectonty,  or  excision  of  a  por- 
tion of  a  nerve-trunk,  is  only  applicable  to  sensory  nerves 
and  to  painful  affections. 

Stretching  of  the  Sciatic  Nerve. — Some  surgeons 
stretch  the  sciatic  nerve  by  anesthetizing  the  patient  and 
holding  the  leg  and  thigh  in  line,  strong  flexion  being  made 
upon  the  hip,  the  entire  lower  extremity  being  used  as  a 
lever  (Keen).  This  method,  which  has  caused  death,  inflicts 
needless  damage,  and  the  operative  plan  is  safer  and  better. 
The  instruments  required  are  a  scalpel,  hemostatic  forceps,  ♦ 
dissecting-forceps,  a  dissector,  retractors,  and  a  scale  with  a 
handle  and  a  hook.  The  patient  lies  prone,  the  thighs  and 
legs  being  extended.  An  incision  four  inches  in  length  is 
made  a  little  external  to  the  middle  of  the  thigh,  and 
going  at  once  through  the  deep  fascia ;  the  biceps  muscle  is 

1  Med.  Rec,  Dec.  5,  1896. 


NEURECTOMY.  647 

found  and  is  drawn  outward  ;  the  nerve  is  discovered  between 
the  retracted  biceps  on  the  outside  and  the  semitendinosus  on 
the  inside,  resting  upon  the  adductor  magnus  muscle.  The 
nerve,  which  is  caught  up  by  the  finger,  is  first  pulled  down 
from  the  spine  and  then  up  from  the  periphery,  and  finally 
the  hook  of  the  scale  is  inserted  beneath  the  trunk  and  the 
nerve  is  stretched  to  the  extent  of  fort}-  pounds.  V^ery 
rarely  is  even  a  single  ligature  needed.  The  wound  is  sutured 
and  dressed.  If  the  incision  is  made  at  a  higher  level  belo\v 
the  gluteofemoral  crease,  the  sciatic  nerve  will  be  found  just 
by  the  outer  border  of  the  biceps. 

Neurectomy  of  the  Infraorbital  Nerve. — The  instru- 
ments required  in  this  operation  are  a  scalpel,  dissecting- 
forceps,  aneurysm-needle,  hemostatic  forceps,  blunt  hooks, 
a  dissector,  and  metal  retractors.  The  patient  lies  upon 
his  back,  the  head  being  a  little  raised  by  pillows.  The 
surgeon  stands  to  the  outside  of  and  faces  the  patient.  A 
curved  incision  one  and  a  half  inches  long  is  made  below 
the  lower  border  of  the  orbit.  The  nerve  lies  in  a  line 
dropped  from  the  supraorbital  notch  to  between  the  two 
lower  bicuspid  teeth.  The  nerve  is  found  upon  the  levator 
labii  superioris  muscle,  and  a  piece  of  silk  is  passed  under 
the  nerve  by  an  aneurysm-needle  and  firmly  fastened.  The 
upper  border  of  the  incision  is  drawn  upward  ;  the  periosteum 
of  the  floor  of  the  orbit  is  elevated  and  held  by  a  retractor ; 
the  roof  of  the  infraorbital  canal  is  broken  through;  the  nerve 
is  picked  up  far  back  with  the  blunt  hook  and  is  divided  w'ith 
scissors,  and  the  entire  nerve  is  drawn  out  by  making  traction 
upon  the  silk.  The  bleeding  in  the  orbit  is  checked  by  press- 
ure.    The  wound  is  stitched  without  drainage. 

Neurectomy  of  the  Supraorbital  Nerve. — In  this 
operation  shav^e  off  the  eyebrow.  The  instruments  required, 
and  the  position  of  the  patient  are  as  for  the  operation  upon 
the  infraorbital  nerve.  A  curved  incision  one  inch  long  dis- 
closes the  nerve  as  it  emerges  from  the  supraorbital  notch 
or  foramen  at  the  junction  of  the  inner  and  middle  thirds  of 
the  eyebrow.  The  nerve  is  pulled  forward  and  cut  off  above 
and  below^ 

Neurectomy  of  the  Inferior  Dental  Nerve. — The  in- 
struments are  the  same  as  for  any  other  neurectomy,  and  in 
addition  a  chisel,  a  mallet,  and  a  rongeur  forceps.  Make  a 
curved  incision  around  the  angle  of  the  jaw^  Lift  the  supra- 
maxillary  branch  of  the  facial  nerve  downward  (Kocher). 
Separate  the  masseter  muscle  with  a  periosteum-elevator  and 
slight  touches  with  the  knife.    Chisel  an  opening  in  the  center 


648  REMOVAL    OF  GASSERIAX  GANGLTON. 

of  the  ascending  ramus  (Velpeau's  rule).  This  opening  ex- 
poses the  beginning  of  the  dental  canal  (Kocher).  If  neces- 
sary, the  opening  may  be  enlarged  with  a  rongeur.  Pull  the 
nerve  out  with  a  hook  and  remove  a  piece  from  it. 

Removal  of  the  Gasserian  Ganglion. — This  oper- 
ation is  dangerous,  bloody,  and  difficult,  and  is  only  under- 
taken in  very  severe  cases  of  tic  douloureux,  and  in  cases 
upon  which  less  grave  procedures  have  failed.  The  operation 
usually  cures  the  pain  if  the  patient  recovers  from  the 
actual  procedure.  The  mortality  is  from  12  to  15  percent. 
In  some  cases  the  pain  has  subsequently  returned.  Out  of 
Keen's  9  cases  of  removal,  3  had  corneal  trouble,  but  in 
not  one  case  was  the  eye  lost.  Some  atrophy  is  apt  to  be 
noted  in  the  tongue,  and  the  eye  becomes  insensitive  and 
watery. 

Operation. — The  surgeon  is  provided  with  the  instruments 
for  osteoplastic  resection  of  the  skull.  Krause  and  others 
employ  a  surgical  engine.  Special  retractors,  various  hooks, 
scalpels,  a  dry  dissector,  dissecting-  and  hemostatic  forceps, 
and  an  electric  forehead-light  are  required.  Long  strips  of 
gauze  must  be   ready  for  packing  in   case  of  hemorrhage. 


Fig.  231. — Hartley's  osteoplastic  flap  in  removal  of  Gasserian  ganglion  (Tiffany). 

The  patient  is  placed  recumbent,  with  head  turned  to  the 
opposite  side.  A  large  osteoplastic  flap  is  formed  in  front  of 
the  ear  (Fig.  231),  and  is  broken  down.  Hemorrhage  is 
arrested.  It  may  be  found  that  the  meningeal  artery  has 
been  ruptured.  If  this  accident  has  happened,  and  the 
vessel  lies  in  a  bony  canal,  plug  with  Horsley's  wax.  If  the 
vessel  is  bleeding  upon  the  dura,  ligate  by  passing  suture- 
ligatures  around  it.    If  it  is  torn  off  at  the  foramen  spinosum, 


DISEASES    OF    THE   HEAD.  649 

pack  with  iodoform  gauze,  and  postpone  the  rest  of  the 
operation  for  forty-eight  hours.  It  may  be  necessary  at  any 
stage  of  this  formidable  operation  to  pack  the  wound  and  post- 
pone completion  for  two  days.  The  next  step  is  to  lift  up 
the  dura  and  with  it  the  brain  (Fig.  232).     Find  the  inferior 


Fig.  232. — Removal  of  Ga^serian   ganglion  •   a,  middle   meningeal   artery  ;    11,  ophthalmic 
division.  III,  submaxillary  division,  g,  ganglion   (Krause). 

maxillary  nerve  and  clamp  it  with  hemostatic  forceps.  Find 
the  superior  maxillary  nerve  and  clamp  it.  Loosen  the 
nerves  from  their  beds  with  a  dry  dissector.  Twist  the 
clamp-forceps  so  as  to  reel  up  the  nerves.  This  pulls  out 
the  ganglion  intact  with  the  motor  root  and  the  root  of 
origin,  as  far  back  as  the  pons  (Krause's  method).  Arrest 
bleeding ;  close  the  flap ;  sew  the  lids  of  the  affected  side 
together ;  and  cover  the  eye  with  a  watch-crystal. 

XXIII.  DISEASES  AND  INJURIES  OF  THE  HEAD. 

I,  Diseases  of  the  Head. 

In  approaching  cases  of  brain  disorder,  first  endeavor 
to  locate  the  seat  of  the  trouble  ;  next,  ascertain  the  nature 
of  the  lesion ;  and,  finally,  determine  the  best  plan  of  treat- 
ment, operative  or  otherwise.     In  all  operations   upon  the 


650 


D/SEASES  AND   INJURIES    OF   THE   HEAD. 


brain  the  surgeon  must  be  able  to  determine  accurately  the 
situations  of  certain  fissures  and  convolutions,  the  finding  of 
the  situations  of  these  convolutions  and  fissures  comprising 
the  science  of  craniocerebral  topography. 


Fig.  233. — The  meningeal  artery  exposed  by  trephining  (after  Esmarch). 


Tlie  regional  tcnns  used  in  craniocerebral  topography  are 
derived  from  Broca  (Fig.  234).  The  middle  meningeal  artery 
is  found  at  the  pterion,  one  and  one-quarter  inches  posterior 


Fig.  234. — Skull  showing  the  points  named  by  Broca:  As,  asterion  (junction  of  the 
occipital,  parietal,  and  temporal  bones)  ;  basion,  middle  of  anterior  wall  of  foramen  magnum  ; 
B,  bregma  (junction  of  the  sagittal  and  coronal  sutures)  ;  G,  ophryon  (on  a  level  with  the 
superior  border  of  the  eyebrows,  and  corresponding  nearly  to  the  glabella,  the  smooth  swell- 
ing between  the  eyebrows)  ;  g,  gonion  (angle  of  the  lower  jaw)  ;  /,  inion  (external  occipital 
protuberance)  ;  L,  lambda  (junction  of  sagittal  and  lambdoidal  sutures)  ;  N.  nasion  (junc- 
tion of  the  nasal  and  frontal)  ;  Ob,  obelion  (the  sagittal  suture  between  the  parietal  foramina)  ; 
P,  pterion  (point  of  junction  of  great  wing  of  sphenoid  and  the  frontal,  parietal,  and 
squamous  bones.  This  may  be  H -shaped  or  K -shaped,  or  "  retourne,"  in  which  the  frontal 
and  temporal  just  touch)  ;  S,  stephanion  (or,  better,  the  superior  stephanion,  intersection  of 
ridge  for  temporal  fascia  and  coronal  suture)  ;  S' ,  inferior  stephanion  (intersection  of  ridge 
for  temporal  muscle  and  coronal  suture). 


to  the  external  angular  process,  on  a  level  with  the  roof  of 
the  orbit  (Fig.  233).  The  fissures  and  convolutions  of  the 
brain  are  shown  in  Figs.  235-237.  The  fissure  of  Bicliat 
is  marked  by  a  line  on  each   side  drawn  from  the  inion  to 


DISEASES   OE  THE  HEAD. 


651 


the  external  auditor)'  process.  A  line  from  the  glabella  to 
the  inion  overlies  the  median  fissure  and  the  superior  longi- 
tudinal sinus.  The  fissure  of  Rolando  is  ven,'  important,  as 
marking  the  motor  region  of  the  brain.  It  begins  in  the 
median  line,  half  an  inch  posterior  to  the  middle  of  the  dis- 
tance between  the  inion  and  glabella  (Keen).  This  fissure 
runs  downward  and  forward  at  an  angle  of  67.5°  for  a 
distance  of  three  and  three-eighths  inches.  Chiene  finds  the 
fissure  of  Rolando  by  the  following  method :  he  takes  a 
square  piece  of  paper  and  folds  it  into  a  triangle  (Fig.  239,  i ) ; 
the  angle  b  a  c  of  this  triangle  is  45°;  the  edge  d  a 
is  folded  back  on  the  dotted  line  a  e  ;  the  angle  d  a  e 
equals  half  of  45°,  or  22.5°,  and 
the  same  (Fig.  239,  2);  unfold 
c  A ;  in   the   figure   thus  formed  b 


the   angle  c  a  e  equals 

the    paper    in    the     line 

c^45^  and  e  a  c= 


A 


22.5'^  ;  E  A  6=67.5°,  which  is  the  angle  desired.     Place  the 


Fig.  235. — Vie-n-  of  the  brain  from  above  (Ecker). 


point  A  in  the  mid-Hne  of  the  head,  over  the  point  of 
origin  of  the  Rolandic  fissure ;  the  side  a  b  is  laid  along 
the  middle  line  of  the  head,  and  the  line  a  e  corresponds  to 
the  fissure  of  Rolando.^  Fig.  238  shows  Chiene's  scheme 
for  locating  various  points  upon  the  brain.  Horsley 
determines  the  situation  of  the  Rolandic  fissure  by  the  use 

1  Amtrican  Text-book  of  Surgery. 


65: 


DISEASES  AND   INJURIES   OF  THE  HEAD. 


of  his  metal  cyrtometer  (Fig.  240).  He  places  the  point 
marked  zero  over  the  inioglabellar  line  and  midway  be- 
tween the  inion  and  the  glabella.     To  find  the  fissure  of 


Fig.  236.^0uter  surface  of  the  left  hemisphere  of  the  brain  (Ecker). 

Sylvius  (Fig.  236,  .5",  s' ,  s"),  draw  a  line  from  the  exter- 
nal angular  process  to  the  occipital  protuberance.  The 
fissure  of  Sylvius  begins  on  this   line  one  and  one-eighth 


Fig.  237. — Inner  surface  of  the  right  hemisphere  of  the  brain  (Ecker). 


inches  behind  the  external  angular  process ;  the  main 
branch  of  the  fissure  runs  toward  the  parietal  eminence ; 
the  ascending  branch  of  the  fissure  corresponds  to  the 
squamoso-sohenoidal   suture,  and  continues  upward  in  the 


REGIONAL    TERMS. 


653 


same  line  half  an  inch  above  the  suture.  The  preccntral 
sulcus  (Fig.  236,  f)  Hmits  anteriorly  the  ascending  frontal 
convolution ;    it    runs    parallel    with    and    just    behind    the 


Fig.  238.— Chiene's  lines  for  localizing  brain-areas:  mdca,  Rolandic  or  motor  area;  a, 
anterior  branch  of  middle  meningeal  and  bifurcation  of  fissure  of  Sylvius ;  A  c,  horizontal 
part  of  Sylvian  fissure  ;  the  highest  part  of  the  lateral  sinus  touches  ps  at  R ;  MA,  precentral 
sulcus  ;  I,  beginning  of  inferior  frontal  sulcus  ;  K,  beginning  of  superior  frontal  sulcus  ;  M  b  c 
contains  the  supramarginal  convolution  ;  b.  angular  gyrus. 

coronal  suture,  and  a  finger's  breadth  in  front  of  the  fissure 
of  Rolando.  The  intraparictal  fissure  (Figs.  235,  236,  //>) 
limits  the  motor  region  posteriorly.  It  begins  opposite  the 
junction  of  the  lower  and  middle  thirds  of  the  fissure  of 


Fig.  239. — Chiene's  method  of  fixing  position  of  the  Rolandic  fissure  {Ant.  Te.xt-book  of 

Szirgery). 

Rolando,  passes  upward  in  a  line  parallel  with  the  longi- 
tudinal fissure  and  midway  between  the  Rolandic  fissure 
and  the  parietal  eminence,  passes  by  the  parieto-occipital  fis- 


654 


DISEASES  AND   INJURIES   OF   THE   HEAD. 


sure,  and  downward  and  backward  into  the  occipital  lobe. 
The  motor  areas,  which  on  the  outer  surface  are  adjacent  to 
the   fissure  of  Rolando,  are  shown  in   Figs.   235   and  236. 


^.  ■■^i...6l.'.^l...^l...^l..?l....'I..Pl.|.|v..l^.l^.  ..l^..l^...i^...l'...^ 


Fig.  240. — Horsley's  cyrtometer. 

The  superior  longitudinal  sinus  is   overlaid  by  a  line  from 

the  inion  to  the  glabella.  The 
lateral  sinus  is  indicated  by  a 
line  running  from  the  occipital 
protuberance  horizontally  out- 
ward to  a  point  one  inch  pos- 
teriorly to  the  external  auditory 
meatus,  and  from  this  point  by  a 
second  line  dropped  to  the  mas- 
toid process.  The  suprameatal 
triangle  of  Mace  wen  is  bounded 
by  the  posterior  root  of  the  zy- 
goma, the  posterior  bony  wall 
of  the  auditory  meatus,  and  a 
line  joining  the  two.  The  mas- 
toid process  is  opened  through 
Macewen's  triangle  to  avoid  in- 
jury to  the  lateral  sinus.  Bark- 
er's point,  the  proper  spot  to 
apply  the  trephine  in  abscess  of 
the  temporosphenoidal  lobe,  is 
one  and  one-fourth  inches  above 
and  one  and  one-fourth  inches 
behind  the  middle  of  the  external 
auditory  meatus.  Fig.  241  shows 
clearly  the  main  points  of  craniocerebral  topography,  obtained 
by  methods  approv^ed  by  many  scientists. 

Diseases  of  the  Scalp. — The  scalp  is  composed  of  skin, 
subcutaneous  fat,  and  the  occipitofrontalis  muscle  and  apo- 
neurosis.    The  scalp  is  liable  to  inflammation  from  various 


Fig.  241. — Head,  skull,  and  cere- 
bral fissures  :  B  corresponds  to  Broca's 
convolution ;  EAP,  external  angular 
process;  FR,  fissure  of  Rolando  ;  IF, 
inferior  frontal  sulcus  ;  IPF,  intrapari- 
etal  sulcus  ;  MMA,  middle  meningeal 
artery;  OPr,  occipital  protuberance; 
PE,  parietal  eminence  :  POF,  parieto- 
occipital fissure  ;  SF,  Sylvian  fissure; 
A,  its  ascending  limb;  TS,  tip  of  tem- 
porospbenoidal  lobe.  The  pterion  (to 
the  left  of  B)  is  the  region  where  three 
sutures  meet,  viz.,  those  bounding  the 
great  wing  of  the  sphenoid  where  it 
joins  the  frontal,  parietal,  and  tem- 
poral bones  (adapted  from  Marshall 
by  Hare). 


M/CR  O  CEPHA  L  C  'S.  655 

causes,  and  also  to  other  diseases — namely,  tumors,  cysts, 
warts,  moles  (local  cutaneous  hypertrophies),  cirsoid  aneur- 
ysm (page  324),  nevi,  and  lupus.  Abscesses  of  the  scalp  are 
common.  If  an  abscess  forms  beneath  the  pericranium,  the 
pus  diffuses  over  the  area  of  one  bone,  being  limited  by 
the  attachment  of  the  pericranium  in  the  sutures.  If  an 
abscess  forms  in  the  tissue  between  the  occipitofrontalis 
and  the  pericranium,  it  is  widely  diffused.  Treves  calls  this 
subaponeurotic  connective  tissue  "  the  dangerous  area." 
Abscess  of  the  subcutaneous  tissue  is  apt  to  be  limited 
because  of  the  great  amount  of  fibrous  tissue.  Abscess  is 
treated  by  instant  incision  at  the  most  dependent  part,  anti- 
septic irrigation,  and  drainage. 

Diseases  and  Malformations  of  the  Bones  of  the 
Skull. — The  bones  of  the  skull  are  liable  to  caries,  necrosis, 
osteitis,  periostitis,  atrophy,  hypertroph}-,  tumors,  etc.  (see 
Diseases  of  Bones). 

Microcephalus. — By  microcephalus  is  meant  unnatural 
smallness  of  the  head  due  to  imperfect  development.  Marked 
microcephalus  is  not  a  common  condition,  but  it  is  an  occa- 
sional cause  or  associate  of  idiocy.  A  child  may  be  born 
with  a  skull  completely  ossified  even  at  the  fontanelles,  or 
the  ossification  may  become  complete  soon  after  birth,  but 
in  many  cases  of  microcephalus  ossification  takes  place  late 
or  not  at  all.  In  microcephalus  the  face  is  apt  to  be  fairly 
well  developed ;  the  jaws  are  prominent ;  the  forehead  is  flat ; 
the  cranium  and  brain  are  small ;  the  convolutions  of  the 
brain  are  simpler  than  is  natural ;  there  is  apt  to  be  marked 
asymmetr}'  of  the  two  sides  of  the  brain ;  internal  hydro- 
cephalus may  exist ;  areas  of  sclerosis  and  atrophy  are 
common  ;  porencephaly  is  not  unusual.  Some  patients  have 
perfect  motor  power ;  others  are  slow  and  inco-ordinate. 
Epilepsy,  chorea,  and  athetosis  frequently  complicate  the 
case.  Idiots  of  this  t}-pe  often  present  deformities  such  as 
cleft-palate,  strabismus,  distorted  ears,  hypertrophied  tongue, 
deformed  genitals  or  extremities,  ill-shaped  and  irregularh- 
developed  teeth.  They  exhibit  irregular  muscular  move- 
ments, are  frequently  paralyzed  in  childhood  (infantile  para- 
plegia or  hemiplegia),  and  suffer  from  subsequent  contract- 
ures. These  idiots  are  active,  destructive,  excitable,  and 
are  liable  to  be  violent  and  almost  demoniacal.  Clouston 
says   they  look  impish  and  unearthly. 

Treatment. — Skilled  training  in  a  school  for  the  feeble- 
minded or  in  an  institution  for  idiots  is  necessary  in  treating 
microcephalus.     Idiots  have  but  little  power  of  attention. 


656  DISEASES  AND   INJURIES   OF   THE   HEAD. 

and  sensory  impressions  give  rise  to  but  few  concepts,  and 
these  are  feeble  and  fleeting.  In  order  to  educate  the  idiot 
it  is  highly  desirable  that  speech  be  acquired,  and  "  the  more 
strongly  the  attention  can  be  aroused  the  more  perfect  does 
speech  become  "  (Kirchhoff).  The  principle  of  the  educa- 
tion of  idiots  is  to  stimulate,  co-ordinate,  and  guide  sight, 
hearing,  and  feeling. 

Lannelongue  of  Paris  has  suggested  an  operation  in  cases 
of  idiocy  with  premature  ossification  (see  Linear  Craniotomy, 
page  692).  In  this  procedure  the  author  has  no  confidence. 
Idiocy  is  a  general  disorder  and  not  a  local  brain  disease. 
Soft  parts  mould  bone,  and  bone  does  not  mould  soft  parts. 
There  is  no  evidence  that  the  brain  is  being  compressed ;  in 
fact,  the  simplicity  of  the  convolutions  suggests  the  contrary. 
In  many  typical  cases  of  microcephalic  idiocy  there  is  no 
synostosis  even  years  after  birth.  The  operation  has  been 
much  abused.  It  is  sometimes  fatal,  and,  although  a  fatality 
may  gratify  the  family,  a  surgeon  is  not  a  legal  executioner. 
The  remarkable  improvement  which  has  been  reported  in 
some  cases  results  probably  from  misconception ;  the  new 
surroundings,  the  strange  faces,  the  firm  discipline,  the  effect 
of  the  anesthetic,  and  the  shock  of  the  operation  attract  the 
feeble  attention  and  rouse  the  sluggish  senses.  Many  cases 
are  brought  for  operation  because  they  are  for  the  time 
being  unusually  intractable  and  excitable,  and  the  return 
to  the  usual  level  of  conduct  after  operation  is  regarded 
as  a  permanent  gain  when  it  is  often  but  a  temporary  alle- 
viation. We  believe  that  scientific  training  is  the  proper 
treatment,  and  that  the  efficiency  of  training  is  not  in- 
creased by  the  previous  performance  of  craniotomy,  and 
we  follow  the  precept  of  Agnew,  that  a  surgeon  might 
as  well  cut  a  piece  out  of  a  turtle's  back  to  make  a  turtle 
grow  as  to  cut  a  piece  out  of  the  skull  to  make  the  brain 
grow. 

Diseases  and  Malformations  Involving  the  Brain. 
— Meningocele  is  a  congenital  protrusion  of  the  cerebral 
membranes  through  a  bony  aperture,  the  sac  containing 
some  extracerebral  fluid.  Meningocele  feels  and  looks  like 
a  cyst  (is  translucent  and  fluctuates) ;  it  does  not  usually 
pulsate,  it  has  a  small  base,  it  becomes  tense  on  forcible 
expiration,  and  it  may  be  reduced. 

Encephalocele  is  a  congenital  protrusion  not  only  of 
membranes,  but  also  of  a  portion  of  the  brain  as  well,  the 
sac  containing  some  extracerebral  fluid.  Encephalocele  is 
small,  opaque,  does  not  fluctuate,  has  a  broad  base,  does 


// )  -DR  O  CEPHA  L  US.  657 

pulsate,  becomes  tense  on  forced  expiration,  and  attempts 
at  reduction  cause  pressure-symptoms. 

Hydrencephalocele  is  a  congenital  protrusion  of  mem- 
branes and  brain-substance,  the  interior  of  the  mass  com- 
municating with  the  ventricles  and  containing  ventricular 
fluid.  This  is  the  most  frequent  and  the  most  dangerous 
form.  H}-drencephalocele  is  larger  than  a  meningocele,  is 
translucent,  fluctuates,  rarely  pulsates,  is  pedunculated,  is 
rendered  a  little  tense  on  forced  expiration,  and  cannot  be 
reduced.' 

Treatment. — For  hydrencephalocele  nothing  can  be  done, 
and  early  death  is  inevitable.  In  rare  instances  an  enceph- 
alocele  is  converted  into  a  meningocele,  and  the  bony 
aperture  closes,  thus  bringing  about  a  cure.  Among  the 
expedients  for  treating  meningocele  and  encephalocele  are 
electrolysis,  injection  of  Morton's  fluid  (gr.  x  of  iodin, 
gr.  XXX  of  iodid  of  potassium,  5J  of  glycerin),  pressure  and 
excision.  In  cases  of  meningocele,  when  portions  of  the  nerve- 
centers  are  not  contained  in  the  sac,  Mayo  Robson  advises  the 
performance  of  a  plastic  operation.  He  ligates  the  neck  of 
the  sac,  cuts  away  the  sac,  sutures  the  skin-flaps  separately, 
and  leaves  the  stump  outside  the  line  of  superficial  sutures. 
It  is  usually  possible  to  tell  by  palpation  if  nerve-centers  are 
in  the  sac,  but  if  in  doubt,  make  an  exploratory^  incision,  and 
sweep  the  finger  around  inside  of  the  sac." 

Hydrocephalus. — In  external  hydrocephalus  the  fluid  is 
between  the  membranes  and  the  brain ;  in  internal  hydro- 
cephalus the  fluid  is  in  the  ventricles.  Hydrocephalus  may 
be  aeute  or  chrojiic,  congenital  or  acqnired. 

Acute  hydrocephalus,  which  results  from  meningitis 
(particularly  tubercular  meningitis),  is  usually  internal,  but 
may  be  external.  The  symptoms  are  headache,  elevated 
temperature,  delirium,  stupor,  convulsions,  paralysis,  and 
choked  disk. 

Treatment  of  acute  h\'drocephalus  is  of  no  avail.  Tapping 
of  the  ventricles  may  be  tried. 

Chronic  hydrocephalus  is  usually  congenital.  The  cra- 
nium enlarges  enormously  and  the  bones  of  the  skull  are 
widely  separated.  The  broad  forehead  overhangs  the  eyes. 
The  child  is  an  idiot,  and  v'eiy  often  does  not  learn  to  walk 
or  to  talk.  Convulsions  and  palsies  are  common,  and  blind- 
ness is  frequent.     Such  children  usually  die  young. 

The  treatment  of  chronic  hydrocephalus  is  rarely  of  much 

^  American  Text-book  of  Surgeiy. 

''^  Am.  Jour.  Aled.  Sciences,  Sept.,  1895. 


658  DISEASES  AND   INJURIES    OF   THE   HEAD. 

avail.  Pressure  by  strapping  with  adhesive  plaster  has  been 
tried.  Tappings  through  a  fontanelle  may  be  performed  by 
means  of  a  trocar  (only  5ij  or  5iij  of  fluid  being  drawn  at  a 
time).  If  much  fluid  is  drawn,  the  head  must  be  strapped 
afterward.  If  the  skull  ossifies,  the  lateral  ventricles  may  be 
tapped.  It  has  been  proposed  to  drain  by  tapping  the  theca 
of  the  spinal  cord  (Quincke).  This  last  operation  is  called 
lumbar  puncture  (page  713). 

2.  Injuries  of  the  Head. 

Caput  SUCCedaneum  is  a  collection  of  bloody  serum 
under  the  scalp  of  a  new-born  child  and  results  from  the  press- 
ure of  labor.  The  pressure  was  about  but  not  at  the  point 
where  the  bloody  serum  gathered.     No  treatment  is  required. 

Scalp-wounds  are  treated  as  are  other  wounds.  Even  a 
large  piece  of  scalp  with  only  a  narrow  pedicle  may  not 
slough ;  hence  try  to  save  any  piece  that  has  an  attachment. 
Always  shave  a  wide  area  and  disinfect  the  wound  thor- 
oughly. Stitch  the  wound  with  silkworm-gut.  The  hem- 
orrhage can,  in  most  instances,  be  controlled  by  the  sutures 
which  are  used  to  close  the  wound.  If  drainage  is  required, 
use  a  few  strands  of  silkworm-gut. 

Contusions  of  the  Head. — Scalp-swelling  from  hemor- 
rhage is  usually  considerable.  The  patient  may  be  stunned 
or  dazed.  The  swelling  of  hematoma  must  not  be  mistaken 
for  fracture  with  depression.  In  hematoma  there  is  a  cen- 
tral depression,  hard  pressure  on  the  centre  finds  bone  on  a 
level  with  the  general  contour  of  the  bone,  and  the  margin 
of  a  hematoma  is  circular,  is  not  quite  hard,  and  is  elevated 
above  the  general  contour.  In  depressed  fracture  the  edge 
is  on  a  level  with  or  below  the  level  of  the  general  bony  con- 
tour, and  the  margin  is  sharp  and  irregular.  The  treatment 
is  by  means  of  pressure  and  the  use  of  lead-water  and  laud- 
anum.    If  suppuration  arises,  at  once  incise. 

Concussion  or  I^aceration  of  the  Brain. — For  many 
years  it  has  been  customary  .to  regard  concussion  as  a  con- 
dition produced  by  molecular  vibrations  in  the  nervous  sub- 
stance of  the  brain.  Buret's  classical  observations  have  pro- 
foundly modified  surgical  thought,  and  have  led  to  the 
opinion  that  in  concussion  of  the  brain  there  is  injury  to  the 
brain  itself,  a  rupture  of  cerebraLyessels  bro^ght^3ibont_by 
the  ?^d^zan^p  and  reressmn^of__a_waveof  cerebrospinal  fluid. 
This  wave  first  flows  in  the  directian-Ot  tlfe  force.  Keen 
says    that    there    may    be    slight    brain-injuries    which    can 


CONCUSS/ON   OF   THE   BRAIN.  659 

properly  be  called  "  concussions,"  but  it  is  better  to  consider 
concussion  as  synonymous  with  laceration  of  the  brain.  It 
seems,  however,  highly  improbable  that  slight  cases  of  con- 
cussion are  accompanied  by  vascular  rupture  or  organic 
mischief,  the  symptoms  are  too  transitory,  and  reaction  too 
rapid  and  complete  to  permit  of  any  such  view.  These 
slight  cases  are  identical  with  and  at  least  can  not  be  dis- 
tinguished from  shock.  The  cause  of  concussion  is  violent 
force,  either  direct  (as  a  blow  upon  the  head)  or  indirect  (as 
a  fall  upon  the  buttocks).  This  force  shakes,  oscillates,  or 
jars  the  brain,  giving  rise  to  waves  of  cerebrospinal  fluid, 
which  sometimes  rupture  vascular  twigs,  large  vessels,  or 
even  the  membranes.  In  the  slighter  ruptures  concussion 
only  exists ;  in  the  severe  ruptures  compression  soon  arises. 
Symptoms. — In  a  slight  case  of  brain-concussion  the 
patient  may  or  may  not  fall ;  his  face  is  pale ;  he  feels  weak, 
giddy,  nauseated,  and  confused ;  he  often  vomits,  but  soon 
reacts.  In  a  severe  case  he  lies  with  complete  muscular  relax- 
ation, cold  extremities,  pale  and  cold  skin,  shallow  and  quiet 
respiration,  frequent,  small,  soft,  and  irregular  pulse  (pulse 
may  not  be  detectable),  and  fluttering  heart.  He  seems 
unconscious,  but  can  usually  be  roused  to  monosyllabic 
response  by  shouting,  pinching,  or  holding  a  bright  light 
near  his  face.  Occasionally,  however,  there  is  complete  un- 
consciousness. The  urine  and  feces  are  often  passed  in- 
voluntarily. The  pupils  may  be  unaltered,  may  be  dilated  or 
contracted,  or  may  be  equal  or  unequal,  but  in  any  case  they 
will  react  to  light.  Paralysis  rarely  exists,  but  if  there  is 
paralysis  it  is  temporary.  The  temperature  at  first  is  sub- 
normal. In  a  severe  cortical  laceration  there  will  be  twitch- 
ings  or  even  general  convulsions,  or  the  patient  will  lie  curled 
up  with  limbs  flexed  and  eyelids  shut,  and  will  resist  all 
attempts  to  open  his  eyes  or  mouth  or  to  move  his  limbs  (A. 
Pearce  Gould).  Erichsen  called  this  condition  "  cerebral 
irritability."  As  the  patient  reacts  he  will  most  probably 
vomit.  Within  twenty-four  hours  he  usually  improves, 
but  is  feverish  and  complains  of  headache  and  lassitude, 
sometimes  becomes  delirious,  and  in  rare  cases  develops 
mania.  After  concussion  recovery  may  be  complete,  but, 
on  the  contrary,  a  person's  whole  nature  may  change  :  he 
may  develop  hysteria,  insanity,  or  epilepsy,  and  in  many 
cases  there  is  complaint  for  a  long  time  of  headache,  insom- 
nia, low  spirits,  and  lassitude.  If  the  patient  in  concussion 
recedes  from,  instead  of  advancing  toward,  recovery,  coma 
will  set  in  or  inflammation  will  develop.     Keen  states  that 


66o  DISEASES  AND   INJURIES   OE   THE  HEAD. 

the  prognosis  is  always  uncertain.  Any  concussion  pro- 
ducing unconsciousness  is  a  serious  injury,  because  consider- 
able laceration  has  probably  occurred. 

Treatment. — In  treating  brain-concussion,  bring  about 
reaction  by  the  administration  of  aromatic  spirits  of  ammo- 
nia (no  alcohol,  as  this  agent  excites  the  brain),  by  pouring 
a  few  drops  of  ammonia  on  a  handkerchief  and  holding  it 
near  the  nose,  by  surrounding  the  patient  (who  lies  in  bed 
with  a  pillow)  with  hot  bottles,  by  hot  irrigation  of  the  head, 
by  the  application  of  mustard  over  the  heart,  and  by  the 
administration  of  hot  coffee  or  hot  saline  enemata.  Do  not 
pour  fluid  into  the  patient's  mouth  until  he  becomes  able  to 
swallow.  If  he  cannot  swallow,  rely  on  hot  enemata  and 
hypodermatic  injections  of  strychnin.  Place  the  patient  in 
bed  in  a  quiet  room,  and  watch  him.  If  reaction  is  inordinate, 
apply  cold  to  the  head,  give  arterial  sedatives  and  diuretics, 
and  purge.  For  some  days  or  for  some  weeks,  according  to 
the  case,  in.sist  on  an  easy  life.  Give  a  plain  diet  containing 
a  minimum  of  meat,  administer  an  occasional  purgative,  and 
secure  sleep.  Sleep  can  often  be  obtained  by  some  simple 
expedient,  such  as  the  administration  of  warm  milk,  placing 
a  hot-water  bag  to  the  abdomen  or  feet,  or  applying  a  mus- 
tard plaster  for  a  short  time  to  the  back  of  the  neck.  In 
cases  where  obstinate  wakefulness  exists,  it  becomes  neces- 
sary to  give  bromid,  chloral,  sulphonal,  trional,  or  some 
other  hypnotic.  Morphin  is  avoided  because  it  is  thought 
to  increase  venous  congestion  of  the  brain,  but  the  elder 
Gross  often  used  it,  especially  in  cerebral  irritation.  If  signs 
of  compression  arise,  it  is  best  to  trephine,  as  the  compressing 
agent  may  be  a  clot  (see  page  663).  If  inflammation  arises, 
some  surgeons  will  not  trephine ;  but  it  is  wise  and  proper, 
especially  if  the  damage  seems  to  be  localized,  to  incise  the 
scalp  and  inspect  the  bone.  If  a  fracture  is  discovered 
and  the  symptoms  are  serious,  perform  an  exploratory  tre- 
phining, open  the  dura,  and  secure  drainage  for  inflammatory 
products. 

In  any  severe  contusion  the  surgeon  should  at  once 
incise_the  scalp,  and  inspec;^  the  bone.  For  many  weeks 
after  a  grave  concussion  a  patient  must  be  kept  away 
from  business  and  be  watched  because  of  the  possibility 
of  an  abscess__of_the__brain  arising,  and  because  of  the  lia- 
bility of  such  patientsto^develop  hysteria,  neurasthenia,  or 
insanity. 

Compression  of  the  Brain. — The  causes  of  brain- 
compression  are  hernorrhage,  depressed  fracture,  tumor,  in- 


COMFKESSJOX  OF   THE   BRAIN.  66 1 

flamm.-itory  exudate,  pus,  and  foreign  bodies.  Death  tends 
to  happen  from  respiratory  failure,  not  from  heart-failure 
(Horsley). 

Symptoms. — In  great  or  sudden  brain-compression  com- 
plete coma  exists  without  voluntary  movement.  The  skin 
is  hot  and  perspiring ;  the  respirations  are  slow  and  sterto- 
rous, and  the  cheeks  flap  during  expiration  ;  the  pulse  is  slow 
and  full,  and  may  be  irregular ;  the  pupils  are  somewhat 
dilated,  and  do  not  respond  readih*  to  light.  In  a  unilateral 
compression  the  pujDil__on__thg.  side  of  the  compressing-cause 
is  apt  to  be  much  dilated  if  the  compression  is  affecting  the 
base  of  the  brain.  In  cerebral  compression  there  are  usually 
retention  of  urine,  and  often  incontinence  of  feces  ;  paraly.sis 
exists,  which  ma}'  be  ver\-  limited  (monoplegia),  may  be  of 
one  side  (hemiplegia),  or  may  be  general.  In  hemorrhage 
into  the  interior  of  the  brain  the  unconsciousness  is  imme- 
diate or  nearly  so.  In  bleeding  from  the  middle  meningeal 
artery  a  period  of  consciousness  intervenes  between  the  in- 
jury and  the  coma,  in  which  period  blood  collects  and  the 
coma  comes  on  gradually.  In  compression  from  depressed 
fracture  or  from  a  foreign  body  the  symptoms  usually  come 
on  at  once,  but  they  may  be  deferred  for  some  hours.  Com- 
pression from  inflammation  or  pus  begins  gradually  after  a 
considerable  time  has  elapsed. 

A  diagnosis  must  be  made  between  rnriTa  du^  ^^r^  Krain- 
injur^and  the  comatose  conditions  of  apoplexy,  uremia^ 
epilepsy,  hysteria,  diabetes,  nprnm-poisnnincr  and  aicohoik 
intoxication.  In  hospital  practice  cases  of  unconsciousness 
without  a  known  histor}'  are  frequent.  In  attempting  this 
diagnosis  examine  carefully  for  any  evidence  of  traumatism, 
and  inquire  as  to  how  and  where  the  patient  was  found,  if 
any  fit  occurred,  and  if  a  bottle  or  a  pill-box  was  found  near 
by  or  in  the  pockets.  The  surgeon  should  himself  exam- 
ine the  pockets.  Smell  the  breath  to  notice  alcohol  or 
opium,  but  always  remember  that  a  man  may  be  stricken 
with  apoplexy  while  he  is  drunk,  and  may  fracture  his 
skull  by  falling  when  under  the  influence  of  opium  or  of 
alcohol.  Draw  the  urine  with  the  catheter  if  any  water  is  in 
the  bladder;  examine  the  urine  for  albumin  and  alcohol, 
and  take  the  specific  gravity.  In  doubtful  cases  of  coma 
use  the  ophthalmoscope.  In  post-cpilcptic  covia  the  tempera- 
ture is  never  below  normal,  there  are  no  unilateral  symptoms, 
the  condition  resembles  sleep,  and  the  patient  can  be  aroused. 
Hysterical  coma  occurs  in  boys  and  women ;  there  are  no  ob- 
jective symptoms,  and  the  patient,  though  swallowing  what  is 


662  DISEASES  AND   INJURIES   OF  THE  HEAD. 

put  into  his  mouth,  cannot  be  roused  (Gowers).  In  uremia, 
besides  the  condition  of  the  urine  (and  always  remember 
that  a  person  with  albuminuria  is  apt  to  develop  apoplexy), 
there  is  a  persisten^ubnormal  temperatii'-p  and  rnpviilsion<^ 
are  prone  to  occur.  There  is  edema  of  the  legs,  and 
paralysis  and  stertor  are  absent.  In  apoplexy  hemiplegia 
exists,  and  the  initial  temperature  is  for  a  short  time  sub- 
normal. A  single  convulsion  may  have  ushered  in  the  case. 
Alcolwlic  unconsciousness  is  often  diagnosticated  when  apo- 
plexy really  exists.  A  man  will  smell  of  alcohol  who  has 
had  one  drink,  but  one  drink  will  not  produce  coma ;  hence 
the  smell  of  alcohol  is  not  conclusive.  In  any  case  of 
doubt  some  hours  of  watching  will  clear  up  the  diagnosis. 
Regard  a  doubtful  case  as  serious  until  the  truth  is  clear. 
In  opiinn^poisojiiing  the  pupils  are  contracted  1-o_g  pin-point, 
the  respirations  are  usually  s]ow,  shallow.  and_qm£jL„but  may 
be  stertorous,  but  there  is  no  paralysis.  Always  remember 
that  hemorrhage  into  the  pons  will  produce  pin-point  pupils, 
but  it  also  causes  paralysis  (crossed  paralysis  if  in  the  lower 
half  of  the  pons)  and  high  temperature  with  sweating.  In 
opium-poisoning  the  temperature  is  subnormal.  Iri  diabetic 
coma  the  pupils  will  react  to  a  very  bright  light,  the  tempera- 
ture is  subnormal,  and  the  breath  and  the  urine  smell  like 
chloroform. 

Treatment. — The  treatment  of  brain-compression  depends 
on  the  cause.  Hemorrhage  (extradural  or  subdural)  requires 
trephining  and  arrest  of  bleeding ;  coma  from  depressed  fract- 
ure demands  trephining  and  elevation ;  foreign  bodies  must 
be  removed  ;  abscesses  must  be  evacuated  ;  some  tumors  are 
to  be  removed.  In  cerebral  compression,  if  death  is  threat- 
ened by  respiratory  failure,  make  artificial  respiration,  and  at 
once  trephine  over  the  supposed  region  of  compression 
(Victor  Horsley).  Horsley  has  shown  that  irrigation  of  the 
head  with  hot  water  is  of  great  value  in  bringing  about  reac- 
tion from  shock  in  cases  of  brain-injury. 

Intracranial  hemorrhage  may  be  either  spontaneous  or 
traumatic.  In  the  vast  majority  of  instances  spontaneous 
hemorrhage  comes  from  the  lenticulo-striate  artery  (Char- 
cot's artery  of  cerebral  hemorrhage),  and  produces  apoplexy, 
a  disease  belonging  to  the  physician  except  in  some  ingra- 
vescent cases,  for  which  ligation  of  the  common  carotid  on 
the  same  side  as  the  rupture  is  indicated.  Traumatism  during 
delivery  is  a  not  unusual  cause  of  hemorrhage  from  the  mid- 
dle meningeal  artery  (Richardiere).  A  traumatic  hemorrhage 
may  take  place  (i)  between  the  bone  and  the  dura  {extra- 


INTRACRANIAL   HEMORRHAGE.  663 

dnral) ;  (2)  between  the  dura  and  the  brain  [subdural) ;  and 
(3)  in  the  brain-substance  {cerebral). 

(i)  Extradural  hemorrhage  arises  from  the  middle 
meningeal  or,  more  often,  from  one  of  its  branches.  A 
spicule  of  bone  may  penetrate  a  venous  sinus  and  pro- 
duce extradural  hemorrhage,  or  a  sinus  may  rupture.  Rupt- 
ure of  the  meningeal  artery  or  one  of  its  branches  is  usu- 
ally, but  not  always,  accompanied  by  fracture ;  in  fact,  in 
some  cases  not  even  a  bruise  can  be  found.  The  ruptured 
vessel  may  be  upon  the  opposite  side,  hence  the  evidence  of 
scalp-injury  is  not  a  certain  sign  of  the  side  of  the  skull 
involved.  The  accident  may  or  may  not  cause  temporary 
unconsciousness ;  but  even  if  it  does,  from  this  unconscious- 
ness the  patient  almost  always  reacts,  and  there  is  a  distinct 
period  of  consciousness  between  the  accident  and  the  lasting 
coma,  the  coma  being  due  to  pressure  from  a  continually  in- 
creasing mass  of  extravasated  blood.  If  the  main  trunk  or 
a  large  branch  is  ruptured,  the  period  of  consciousness  is 
short ;  if  a  small  branch  is  ruptured,  the  period  of  conscious- 
ness is  prolonged  for  hours  or  perhaps  for  days.  As  the  clot 
forms  and  enlarges  the  patient  becomes  heavy,  dull,  stupid, 
and  sleepy,  he  sleeps  so  soundly  he  can  scarcely  be  aroused 
and  snores  loudly,  and  finally  passes  into  stupor  and  then  into 
coma.  The  other  signs  of  this  condition  are  paralysis  of  the 
side  opposite  the  blood-clot  (not  necessarily  of  the  side  op- 
posite the  injury,  for  the  artery  may  rupture  from  contre-coup 
on  the  uninjured  side);  this  paralysis  is  apt  at  first  to  be 
localized,  but  it  gradually  and  progressively  widens  its  do- 
main. If  the  clot  extends  toward  the  base,  the  pupil  on  the 
same  side  as  the  clot  ceases  to  react  to  light,  becomes  immob- 
ile and  dilates  widely,  and,  if  the  clot  be  on  the  left  side, 
aphasia  is  noted.  As  the  clot  enlarges  adjacent  centers 
become  involved.  The  face  becomes  paralyzed,  then  the  arm, 
and  finally  the  leg.  Not  unusually  epileptiform  attacks  occur, 
starting  in  discharges  from  the  centers  which  are  irritated  by 
the  advancing  clot  before  their  function  is  abolished  by  press- 
ure. The  pulse  becomes  full,  strong,  usually  slow,  but 
occasionally  frequent ;  the  breathing  becomes  stertorous ; 
the  temperature  rises,  that  of  the  paralyzed  side  exceeding 
that  of  the  sound  side.  In  a  compound  fracture  the  pressure 
of  escaping  blood  may  force  brain-matter  out  of  the  wound 
(Keen).  In  extradural  hemorrhage  from  a  sinus  the  symp- 
toms cannot  be  differentiated  from  those  produced  by  arterial 
rupture. 

Treatment. — In  treating  extradural    hemorrhage    localize 


664  DISEASES  AND   INJURIES   OF   THE   HEAD. 

the  clot,  not  by  the  seat  of  the  wound  or  contusion,  but 
entirely  by  the  symptoms.  To  reach  the  middle  meningeal 
artery  or  its  anterior  branch,  trephine  one  and  one-fourth 
inches  back  of  the  external  angular  process,  at  the  level  of 
the  upper  border  of  the  orbit  (Kronlein)  (Fig.  233).  If  this 
incision  does  not  expose  the  clot,  trephine  again  at  the  level 
of  the  upper  border  of  the  orbit  and  just  below  the  parietal 
eminence.  The  first  incision  gives  access  to  the  trunk  and 
to  the  anterior  branch  ;  the  second  incision  exposes  the  poste- 
rior branch.  If  signs  indicate  that  the  clot  is  travelling  to 
the  base,  the  trephine  should  be  used  half  an  inch  lower 
than  the  point  first  indicated.  Arrest  bleeding  by  a  suture 
ligature  or  by  packing  (page  340),  and  always  open  the  dura 
and  inspect  the  brain.  By  this  procedure  a  subdural  hem- 
orrhage may  be  discovered  which,  without  it,  would  have 
been  missed.     Drainage  must  be  employed. 

(2)  Subdural  hemorrhage  is  usually  due  to  depressed 
fracture  and  rupture  of  the  middle  cerebral  artery  or  of 
a  number  of  small  vessels.  The  symptoms  are  identical  with 
those  of  extradural  bleeding,  but  are  usually  very  rapid  in 
onset. 

The  treatment  {•&  trephining  at  the  first  point,  enlarging  the 
opening  upward  and  backward  with  a  rongeur,  opening  the 
dura,  turning  out  the  clot,  Hgating  the  bleeding  point  or 
packing,  elevating  any  depression  of  bone,  draining,  and 
stitching  the  dura  with  catgut.  Hemorrhage  from  internal 
pachymeningitis  requires  the  same  treatment. 

(3)  Cerebral  Hemorrhage. — The  symptoms  of  cerebral 
hemorrhage  are  identical  with  those  of  apoplexy.  The  treat- 
ment is  the  same  as  that  for  apoplexy,  except  in  ingravescent 
cases,  when  the  common  carotid  on  the  same  side  as  the 
clot  may  be  ligated. 

Rupture  of  a  sinus  usually  arises  from  compound  fract- 
ure or  during  a  brain-operation.  The  treatment,  if  the 
rupture  happens  from  fracture,  is  trephining.  Enlarge  the 
opening  by  the  rongeur,  pack  with  one  large  piece  of  iodo- 
form gauze,  or  catch  the  rent  with  hemostatic  forceps,  leav- 
ing them  in  place  for  three  or  four  days,  or  apply  a  lateral 
ligature  or  a  suture  ligature.  Elevate  depressed  bone.  In 
rupture  during  an  operation  control  hemorrhage  by  packing. 

Fractures  of  the  skull  may  be  simple,  compound,  de- 
pressed, non-depressed,  or  punctured.  They  are  divided  into 
fractures  of  the  vault,  usually  due  to  direct  force,  and  fract- 
ures of  the  base,  due  to  extension  of  fractures  of  the  vault, 
to  indirect  violence  (a  fall  upon  the  feet,  the  buttocks,  or  the 


FRACTCJ^ES   OF   TIIE   SKULL. 


665 


vault),  to  forcing  of  the  condj-les  of  the  lower  jaw  against  or 
through  the  base,  or  to  foreign  bodies  breaking  through  the 
orbit,  vault  of  the  pharynx,  the  ear,  or  the  roof  of  the  nos- 
trils. Fracture  by  contre-coup,  w^hich  occurs  on  the  side 
opposite  the  application  of  the  \-iolence,  is  x^xy  rare.  Fract- 
ures of  the  skull  are  uncommon  in  early  youth,  but  the}' 
are  much  more  frequent  in  the  aged.  Usually  the  entire 
thickness  of  the  bone  is  fractured,  but  either  the  outer  or 
the  inner  table  may  be  broken  alone.  In  complete  fractures 
the  inner  table  is  broken  more  extensively  than  is  the  outer 
table,  because  the  inner  table  is  the  more  brittle,  because  the 
force  diffuses,  and  also,  as  Agnew  taught,  because  the  inner 
table  is  part  of  a  smaller  curve  than  is  the  outer  table,  and 
violence  forces  bone-elements  together  at  the  outer  table,  but 
tears  them  asunder  at  the  inner  table  (Figs.  242,  243). 


Fig.  242. — Section  of  outer  and  inner 
tables,  witli  two  parallel  lines  (after  Ag- 
new). 


Fig.  243. — Greater  yielding  of  the  inner 
table  than  of  the  outer  after  the  applica- 
tion of  violence  (after  Agnew). 


Fractures  of  the  Vault. — A  fracture  of  the  vault  of  the 
skull  may  be  simple  and  undepressed,  or  it  may  be  depressed, 
compound,  or  comminuted.  A  mere  crack  may  exist  in  a 
bone,  and  if  a  rent  exists  in  the  soft  parts,  a  bit  of  dirt  or  a 
hair  may  be  caught  in  the  crack.  Fractures  of  the  vault 
arise  from  direct  force.  A  fissure  may  escape  recognition, 
although  in  some  cases  percussion  gives  a  "  cracked-pot " 
sound.  Any  considerable  depression  can  be  detected.  Tn  a 
simple  fracture  occasionally  the  cerebrospinal  fluid  collects 
under  the  scalp  and  forms  a  tumor  which  pulsates  and  be- 
comes tense  on  forcible  expiration  (puffy  tumor  of  Pott). 
Compound  fractures  can  be  readily  recognized,  but  do  not 
mistake  a  suture,  a  Wormian  bone,  or  a  tear  in  the  pericra- 
nium for  a  fracture.  A  fissured  fracture  is  marked  by  a  dark 
line  of  blood  which  sponging  will  not  remove.  Fracture  of 
the  inner  table  alone  can  only  be  suspected  (Keen).  The 
prognosis  of  fractures  of  the  vault  depends  upon  the  extent 
of  brain-injury  rather  than  upon  the  extent  of  bone-injury. 
Simple  fractures  unite  by  bone ;  compound  fractures  with 
loss  of  bone  unite  only  by  fibrous  tissue.     The  dangers  may 


666  DISEASES  AND   INJURIES   OF   THE  HEAD. 

be  iinuicdiatc  (hemorrhage,  brain-injury,  and  septic  inflamma- 
tion) or  be  distant  (epilepsy,  insanity,  and  persistent  headache). 

Treatment. — A  simple  fracture  without  depression  and 
without  brain-symptoms  is  treated  expectantly  (by  rest, 
quiet,  low  diet,  purgation,  moderate  elevation  of  and  cold  to 
the  head,  and  arterial  sedatives).  A  simple  fracture  with 
moderate  depression  and  without  cerebral  symptoms  is 
treated  expectantly,  and  so  also  is  a  simple  fracture  in  which 
symptoms  existed  but  are  abating.  Simple  fracture  with 
marked  depression  requires  immediate  trephining,  even  when 
brain-symptoms  are  absent.  Some  surgeons  make  an  excep- 
tion in  young  children,  and  wait  awhile  before  trephining, 
in  the  expectation  that  the  expansile  brain  will  lift  the  de- 
pressed but  elastic  bone  up  to  the  level.  Trephining  in 
cases  where  no  symptoms  exist,  although  there  is  marked 
depression,  often  prevents  disastrous  consequences  arising 
in  the  future,  and  is  known  as  "  preventive  trephining " 
(Agnew,  Keen,  Horsley,  Macewen,  v.  Bergmann,  and 
others).  In  all  compound  fractures,  shave  and  asepticize 
the  entire  scalp,  enlarge  the  incision,  and  explore  the  bone. 
If  a  fissure  exists  it  must  be  asepticized,  and  if  a  hair  or  other 
foreign  body  is  found  in  it,  in  order  to  effect  removal  and  se- 
cure asepsis  the  outer  table  of  the  skull  must  be  cut  away 
with  a  chisel,  the  fissure  being  thus  converted  into  a  broad 
groove.  In  a  compound  fracture  with  much  depression, 
trephine,  elevate,  and  irrigate.  In  any  fracture,  trephine  if 
distinct  symptoms  exist.  In  punctured  wounds  of  the  brain 
(punctured  fractures),  always  trephine,  open  the  dura,  and 
disinfect  (Keen).  In  any  case  of  fracture  of  the  vault  where 
trephining  has  been  performed,  it  is  wise  to  open  the  dura 
and  examine  the  brain. 

Fractures  of  the  Base. — A  fracture  of  the  base  of  the 
skull  may  exist  in  only  one  of  the  three  fossae,  in  two  of 
them,  or  it  may  involve  all.  The  middle  fossa  is  oftenest 
involved.  Fracture  of  the  posterior  fossa  is  the  most  fatal. 
These  fractures  may  be  due  to  direct  violence,  to  indirect 
force,  and  to  extension  of  a  fracture  of  the  vault.  Extension 
from  the  vault  is  always  by  the  shortest  route.  Fracture  by 
direct  violence  may  arise  from  the  penetration  of  the  nasal 
roof,  the  orbital  roof,  or  the  pharyngeal  roof  by  a  foreign 
body.  The  posterior  fossa  may  suffer  from  a  fracture  by 
direct  violence  applied  to  the  neck.  Fractures  by  indirect 
force  may  arise  from  blows  upon  the  frontal  bone  (the  orbital 
portion  of  the  frontal  or  the  cribriform  process  of  the  eth- 
moid breaking),  from  falls  upon  the  chin  (the  condyle  of  the 


FRACTURES   OF  THE   SKULL.  667 

jaw  breaking  the  middle  fossa),  or  from  falls  upon  the  but- 
tocks, the  knees,  or  the  feet  (fracture  occurring  in  the  poste- 
rior fossa).  The  base  is  very  rarely  broken  by  contre-coup 
(Treves). 

Symptoins. — Fractures  of  the  base  of  the  skull  are  apt  to  be 
compound.  A  solution  of  continuity  in  the  pharynx,  roof 
of  the  nares,  orbit,  or  ear,  permits  access  of  air  to  the  seat 
of  fracture  and  allows  blood  and  cerebrospinal  fluid  to  flow 
externally.  In  fracture  of  the  anterior  fossa  the  fracture 
may  be  compound,  because  of  laceration  of  the  mticous  mem- 
brane of  the  nares  or  of  the  conjunctiva.  Blood  may  run 
from  the  nose,  its  source  being  the  vessels  of  the  mucous 
membrane  or  the  dura,  the  fracture  being  compound.  Epis- 
taxis  does  not  prove  the  fracture  to  be  compound,  but  only 
suggests  it ;  but  if  the  epistaxis  is  prolonged,  the  probability 
is  greatly  increased ;  and  if  the  flow  of  blood  is  succeeded  by  a 
flow  of  cerebrospinal  fluid  the  diagnosis  of  compound  fracture 
is  positive.  Cerebrospinal  fluid  only  appears  when  the  mu- 
cous membrane,  the  dura,  and  the  arachnoid  are  each  lacer- 
ated (Treves).  In  fractures  of  the  anterior  fossa  blood  is  apt 
to  flow  into  the  orbit,  producing  subconjunctival  ecchymosis, 
and  some  blood  is  often  swallowed  and  vomited.  In  fractures 
of  the  middle  fossa  blood  may  flow  from  the  ear  through  a 
tear  in  the  tympanum,  its  source  being  the  vessels  of  the 
tympanum,  the  meningeal  vessels,  or  a  sinus.  Blood  may 
flow  through  the  Eustachian  tube  and  come  from  the  nose, 
may  be  spit  up,  or  may  be  swallowed  and  vomited.  In  many 
cases  a  quantity  of  cerebrospinal  fluid  flows  from  the  ear,  the 
discharge  being  increased  by  expiratory  effort  and  a  position 
which  favors  gravity.  The  cerebrospinal  fluid  must  not  be 
confused  with  either  blood-serum  or  liquor  Cotunnii.  The 
cerebrospinal  fluid  is  always  present  in  large  amount ;  the 
liquor  Cotunnii  can  only  be  present  in  minute  amount. 
Blood-serum  is  highly  albuminous ;  cerebrospinal  fluid  is 
a  serous  fluid  of  very  low  specific  gravity,  never  shows  more 
than  a  trace  of  albumin,  and  contains  considerable  chlorid 
of  sodium  and  in  some  instances  sugar,  which,  when  present, 
reacts  to  Trommer's  and  to  Moore's  tests,  but  does  not  reflect 
polarized  light  nor  ferment  Avith  yeast  (Keetley,  from  Collins). 
Treves  states  ^  that  cerebrospinal  fluid  cannot  flow  from  the 
ear  in  fractures  of  the  middle  fossa  unless  (i)  the  line  of 
fracture  crosses  the  internal  meatus,  (2)  unless  the  prolonga- 
tion of  the  membranes  into  the  meatus  is  torn,  (3)  unless  a 
communication  exists  between  the  internal  ear  and  tympa- 

^  Applied  Anatomy. 


668  DISEASES  AND   INJURIES   OE   THE  HEAD. 

num,  and  (4)  unless  the  drum-membrane  is  torn.  Miles  of 
Edinburgh  ^  claims  that  bleeding  from  the  ear  followed  by  a 
flow  of  cerebrospinal  fluid  is  not  pathognomonic  of  fracture 
of  the  middle  fossa  of  the  base.  He  maintains  that  when 
the  drum  is  ruptured  we  may  have  these  signs,  when  bone 
is  not  broken,  the  chief  source  of  the  blood  being  the  vessels 
of  the  pia  and  temporosphenoidal  lobe,  the  blood  and  cere- 
bro.spinal  fluid  flowing  inside  the  sheath  of  the  auditory 
nerve,  passing  into  the  vestibule,  through  the  lamina  crib- 
rosa,  and  from  the  vestibule  into  the  middle  ear,  finding  exits 
from  this  space  by  way  of  the  Eustachian  tube,  and  also 
through  the  rent  in  the  drum-membrane.  Profuse  serous 
discharge  may  flow  from  the  ear  after  an  injury  without  fract- 
ure when  the  drum  is  ruptured,  the  fluid  coming  from  the 
cells  of  the  mastoid.  It  must  h&  understood  that  fracture 
of  the  base  may  exist  when  there  is  no  flow  of  blood  or  of 
serous  fluid.  A  fracture  of  the  middle  fossa  is  usually  com- 
pound, made  so,  even  when  the  drum  is  not  ruptured,  by 
the  Eustachian  tube.  In  fracture  of  the  posterior  fossa  blood 
accumulates  beneath  the  deep  fascia  and  produces  discolora- 
tion in  the  line  of  the  posterior  auricular  arteiy  (Battle's 
sign),  the  discoloration  first  appearing  near  the  tip  of  the 
mastoid.  The  discoloration  appears  in  the  line  of  nerves 
and  vessels  which  emerge  from  the  deep  fascia,  the  vessels 
passing  through  openings  and  the  extravasated  blood  emerg- 
ing from  the  .same  openings.  Fractures  of  the  posterior  fossa 
are  apt  to  be  compound  through  the  pharynx,  and  in  such 
cases  the  patient  spits  or  vomits  blood.  Compound  fract- 
ures of  the  posterior  fossa  are  more  fatal  than  fractures  in 
either  of  the  other  fossae.  Fractures  of  the  base  are  apt  to 
be  associated  with  paralysis  of  cranial  nerves.  Optic  neuritis 
often  arises  after  the  first  week.  Keen  says  that  in  fractures 
of  the  base  the  temperature  is  subnormal  during  the  shock, 
rises  to  100°  to  101°,  falls  again  to  a  little  below  normal,  and 
remains  normal  or  subnormal  unless  there  be  inflammation 
or  sepsis. 

Treatment. — In  treating  a  compound  fracture  of  the  base 
of  the  skull,  collect  any  serous  discharge  and  analyze  it,  and 
disinfect  any  cavity  involved.  In  fractures  of  the  middle  fossa 
with  ruptured  drum  clean  the  ear  mechanically,  wash  it  out 
with  hydrogen  peroxid  and  with  a  stream  of  warm  corrosive- 
sublimate  solution  of  a  strength  of  i  :  2000  (turn  the  head 
toward  the  affected  side  while  washing,  so  that  the  mercurial 
solution  will  not  run  down  the  Eustachian  tube),  pack  with 

'  Edinburgh  Med.  Jour.,  Nov.,  1895. 


IIVL'.VDS   OF   THE   BRAIX.  669 

iodoform  gauze,  and  apph"  an  antiseptic  dressing.  Several 
times  daily  the  ear  is  to  be  irrigated,  and  insufflated  with  iodo- 
form. The  nasopharynx  must  be  frequently  irrigated  with 
normal  salt  solution  or  boric-acid  solution,  and  insufflated 
with  iodoform.  The  conjuncti\'al  sac  is  frequently  irrigated 
with  boric-acid  solution.  If  after  a  head-injury  blood  accu- 
mulates back  of  the  drum,  this  membrane  should  be  incised 
to  permit  of  drainage  and  disinfection.  In  fractures  of  both  the 
middle  and  anterior  fossee  the  nasopharynx  must  always  be 
cleaned.  The  exact  method  depends  on  the  choice  of  the 
surgeon.  We  may  wash  out  these  cavities  frequenth'  with 
hot  water,  next  with  peroxid  of  hydrogen,  and  finally  with 
boric-acid  solution,  or  can  use  normal  salt  solution.  Insuf- 
flate the  nasophar}-nx  with  iodoform,  and  pack  the  nose 
with  iodoform  gauze  (Keen,  Dennis);  also  cleanse  the  con- 
junctival sac  frequently.  In  some  cases  drainage  has  been 
obtained  from  the  anterior  fossa  by  breaking  down  the  crib- 
riform plate  and  introducing  a  tube  through  the  nostril 
(Allis),  and  from  the  middle  fossa  by  trephining  above  and 
behind  the  external  auditory  meatus.  In  a  compound  fract- 
ure of  the  orbit  disinfect  and  drain.  It  may  be  necessary  to 
trephine  the  roof  of  the  orbit  for  drainage.  In  fracture  of 
the  posterior  fossa  examine  to  see  if  the  fracture  is  com- 
pound, into  the  pharynx,  and  if  it  is  cleanse  with  great  care 
the  nasopharynx,  and  mouth,  as  previously  directed.  In  a 
vtxy  extensive  fracture  of  the  base,  besides  use  of  the 
methods  set  forth  above,  the  entire  head  should  be  shaved 
and  a  plaster  cap  be  applied.  Cases  of  fracture  of  the  base 
must  be  put  into  a  quiet  and  darkened  room  and  be  kept 
upon  a  low  diet,  sleep  being  secured,  and  the  bowels  and 
bladder  being  attended  to.  If  we  are  not  sure  whether  a 
fracture  exists  or  not,  keep  the  man  quiet  and  in  a  darkened 
room,  and  on  a  low  diet.  Attend  to  the  bladder,  keep  the 
bowels  loose,  examine  the  nasophan,'nx  with  mirrors  and 
the  drum  through  a  speculum. 

Wounds  of  the  brain  are  produced  by  violence  and  by 
foreign  bodies  (knives,  bullets,  etc.).  Except  when  due  to 
penetration  of  a  fontanelle  in  a  child  or  of  a  parietal  foramen 
in  adults,  wounds  of  the  brain  are  accompanied  by  fracture 
of  the  skull.  These  wounds  are  ver>'  dangerous  :  foreign 
bodies  (bone,  hair,  clothing,  etc.)  are  often  lodged  in  the 
brain,  hemorrhage  is  usually  severe,  and  sepsis  is  almost 
inevitable  without  proper  treatment.  These  cases  are  very 
fatal,  though  some  astonishing  recoveries  are  on  record. 

The  symptoms  of  brain-wounds  may  be  slight  and  long- 


6/0  DISEASES  AND   INJURIES   OE   THE   HEAD. 

deferred  or  may  be  immediate  and  overwhelming;  they 
depend  upon  the  site  and  extent  of  the  injury.  LocaHzing 
symptoms  may  exist,  and  encephahtis  with  coma  is  apt  to 
arise.     Abscess  not  unusually  follows. 

In  treating  wounds  of  the  brain  always  shave  the  entire 
scalp  and  examine  the  weapon,  if  possible,  to  see  if  a  piece 
were  broken  off.  Asepticize,  enlarge  the  wound,  trephine, 
arrest  bleeding,  elevate  any  depression,  remove  foreign 
bodies,  irrigate  the  wound,  suture  the  dura,  drain,  and  dress. 

Gunshot- wounds  of  the  Head. — A  penetrating  wound 
is  one  in  which  the  bullet  enters  the  head,  but  does  not 
emerge;  a  perforati)ig  wound  is  one  in  which  the  bullet 
passes  through  the  head  and  emerges.  The  bullet  of  the 
modern  rifle  will  rarely  lodge,  but  a  pistol-bullet  will  often 
lodge.  The  wound  of  entrance  is  small ;  the  wound  of  exit 
is  large.  At  the  wound  of  entrance  the  inner  table  is  more 
extensively  fractured  than  the  outer  table  ;  at  the  wound  of 
exit,  the  outer  table  is  more  widely  broken  than  the  inner 
table.  In  these  cases  there  is  always  great  concussion,  and 
concussion-symptoms  exist  even  when  the  bullet  has  not 
entered  the  brain.  In  moderate  concussion  the  action  of 
the  heart  is  retarded;  in  severe  concussion  it  is  accelerated.^ 
A  bullet  may  be  lodged  within  the  cranium  when  merely  a 
fracture  without  a  bullet-hole  can  be  detected.  In  these 
cases  the  bullet  produces  a  fracture  and  enters  the  cranium, 
and  then  the  depressed  bone  flies  back  into  place  (v.  Berg- 
mann).  In  such  cases  if  complete  perforation  occurs,  the 
one  existing  opening  is  the  opening  of  exit.  A  bullet 
may  lodge  in  the  bone,  between  the  dura  and  the  bone, 
in  the  brain,  between  the  dura  and  bone  of  the  opposite 
side,  or  in  the  bone  of  the  opposite  side,  in  the  nasal  fossa, 
maxillary  antrum,  or  orbit.  Always  examine  the  side  of  the 
head  opposite  to  the  wound  of  entrance  to  determine  if  there 
is  any  bulging  or  fracture.  A  bullet  may  pass  or  cross 
the  brain  and  be  deflected  from  the  inner  surface  of  the 
skull  (Fluhrer).  Ruth  does  not  believe  the  bullet  can  re- 
bound from  the  opposite  wall.^  The  secondary  symptoms  of 
gunshot-wounds  of  the  head  are  varied  and  uncertain,  and 
may  not  be  observed  at  all  before  death.  Fowler  wisely 
points  out  that  a  patient  with  a  gunshot-wound  of  the 
head  may  have  also  received  other  injuries,  and  the  other 
injuries  may  be  in  part,  at  least,  responsible  for  cerebral 
symptoms. 

^  Fowler,  in  Annals  of  Surgery,  Nov.,  1895. 

^  See  the  instructive  article  by  Fowler,  in  Annals  of  Surgery,  Nov.,  1S95. 


GL'XSNOT-irOLW'DS    OF   THE   HEAD.  6/1 

Treatment. — Bring  about  reaction  (see  Concussion).  In 
.severe  cases  apply  heat  to  the  head,  and  make  artificial  respi- 
ration. It  will  sometimes  be  necessary  to  operate  while  arti- 
ficial respiration  is  being  made.  In  treating  gunshot-wounds 
of  the  head  shave  and  asepticize  the  whole  scalp,  disinfect  the 
entire  track  of  the  ball,  and  arrest  hemorrhage  at  the  wounds 
of  entrance  and  exit,  using  the  rongeur  to  expose  the  bleed- 
ing points  if  the  bullet  be  large,  employing  the  trephine  if  it 
be  small.  If  the  bullet  has  emerged  and  has  been  picked  up, 
examine  it  to  see  if  it  is  entire.  The  bullet,  if  retained,  is  to  be 
sought  for.  Place  the  head  in  such  a  position  that  the  track 
of  the  ball  will  be  vertical,  then  introduce  Fluhrer's  aluminum 
probe  and  let  it  find  its  way  by  gravity.  The  probe  may  find 
the  ball  near  the  wound  of  entrance,  in  which  case  extract 
the  ball  with  forceps ;  or  the  probe  ma}'  find  the  ball  near 
the  opposite  side  of  the  head,  in  which  case  make  a  counter- 
opening  through  the  bone  at  a  point  the  probe  would  touch 
if  it  were  pushed  entirely  across.  Take  a  new  and  c/ca7i 
rubber  catheter  (Xo.  9,  French),  insert  a  stylet,  and  carr}-  the 
catheter  through  the  wound  (Keen).  Knowing  the  depth  of 
the  ball,  search  for  it  around  the  catheter-tube  as  an 
axis,  and  when  found  extract  it.  After  extraction  drain 
the  wound  by  means  of  a  tube.  A\'hen  a  counter-opening 
exists  drain  through  and  through.  If  the  ball  cannot  be 
detected,  drain  by  a  tube  carried  to  the  depths  of  the  wound. 
After  dressing  always  place  the  head  in  a  position  favor- 
able for  drainage.  Fluhrer  tells  us  that  when  a  counter- 
opening  fails  to  disclose  the  bullet,  use  the  new  opening 
as  a  doorway  through  which  to  search  for  the  ball.  He 
believes  the  bullet  is  not  unusually  deflected.  The  angle 
of  reflection  is  somewhat  greater  than  the  angle  of  in- 
cidence, and  the  bullet  is  apt  to  fall  a  little  toward  the 
base.  Splinters  of  bone  are  often  dri\"en  into  the  brain 
b}-  a  bullet,  and  these  are  removed  whether  the  ball  is 
found  or  not.  Several  varieties  of  probes  have  been  com- 
mended. Fluhrer  uses  a  large-sized  aluminum  probe.  Senn 
uses  an  instrument  shaped  like  the  Xelaton  probe,  but  of  the 
same  diameter  as  the  bullet.  (Of  course,  the  porcelain  probe 
will  not  show  a  black  mark  from  contact  with  a  modern 
bullet.)  Fowler  uses  a  graduated  pressure-probe ;  so  long 
as  the  pressure  is  within  the  limits  of  the  spring,  as 
shown  by  the  scale,  the  probe  is  in  the  bullet-track. 
Girdner's  telephonic  probe  is  a  valuable  aid  to  diagnosis. 
Recently  bullets  have  been  located  by  the  Rontgen  rays. 
There  can  be  no  doubt    that    manv  eunshot-wounds  ha\-e 


6/2  DISEASES  AND   INJURIES   OF   THE  HEAD. 

been  recovered  from  without  operation,  and  there  can  be  no 
doubt  that  many  deaths  follow  operation  (about  33^  per  cent, 
according  to  Hahn).  Von  Bergmann  is  so  impressed  with 
these  facts  that  he  does  not  operate  when  symptoms  are 
absent. 

FungTlS  cerebri  (hernia  of  the  brain)  rarely  contains  true 
brain-substance.  It  is  in  most  instances  a  growth  from  the 
neuroglia.  Hernia  cerebri  cannot  occur  if  the  dura  is  not 
opened ;  it  is  rare  in  any  case  unless  the  brain  is  damaged, 
and  is  most  frequent  after  septic  wounds.  In  any  brain- 
operation  where  the  dura  is  opened  suture  it ;  or,  if  there  be 
a  great  gap  in  the  dura,  turn  in  a  flap  of  pericranium,  its 
bone-forming  surface  being  upward,  and  stitch  this  mem- 
brane to  the  dura  (Keen).  The  evidence  of  brain-hernia  is  a 
protruding  mass  which  is  soft,  lobulated,  of  a  dirty-white 
color,  pulsating,  painless  to  the  touch,  often  bleeding,  and 
sometimes  discharging  cerebrospinal  fluid.  In  treating 
brain-hernia  employ  antiseptic  dressings.  Skin-grafting 
benefits  some  cases.  Pressure  is  dangerous.  Excision  by 
the  knife  or  cautery  does  no  good.  After  healing,  a  depres- 
sion marks  the  site  of  the  hernia. 

Traumatic  inflammation  of  the  brain  and  its  mem- 
branes is  divided  into  oiccpJialitis  or  ccrcbritis,  inflammation 
of  the  cerebrum  ;  ce7'ebellitis,  inflammation  of  the  cerebellum  ; 
meningitis,  inflammation  of  the  meninges  ;  arachnitis,  inflam- 
mation of  the  arachnoid ;  pachymeningitis,  inflammation  of 
the  dura;  and  leptomeningitis,  inflammation  of  the  arachnoid 
and  pia. 

Pachymeningitis. — Inflammation  of  the  external  layer 
of  the  dura  is  called  pachymeningitis  externa.  It  may  arise 
from  tumor,  caries,  necrosis,  middle-ear  disease,  sunstroke, 
or  traumatism.  Syphilis  is  a  not  unusual  cause.  The  other 
membranes  may  become  involved.  Suppuration  may  arise, 
having  extended  by  contiguity  from  neighboring  parts.  The 
symptoms  of  pachymeningitis  externa  are  uncertain.  They 
resemble  often  those  of  leptomeningitis  (page  673).  Pressure- 
symptoms  may  arise.  Headache  is  always  present.  Paralysis 
may  or  may  not  exist.  If  pus  forms,  the  ordinary  constitu- 
tional symptoms  of  suppuration  arise  (high  temperature  and 
sweats),  not  the  symptoms  of  abscess  in  the  brain.  In  a 
severe  case  the  other  membranes  become  involved. 

The  treatment  consists  in  removing  the  cause  (carious 
bone,  pus,  middle-ear  disease).  In  pachymeningitis  from 
traumatism  it  is  sometimes  advisable  to  trephnie  in  order 
to   drain  inflammatory  products ;  in  a  case  with   locaHzing 


LEPTOMENINGITIS.  673 

symptoms  always  trephine  ;  in  an  ordinary  case,  without  pus 
and  with  no  evidences  of  traumatism,  use  wet  cups  back  of 
the  mastoid  processes,  apply  an  ice-bag  to  the  head,  and 
purge  by  means  of  calomel.  Use  iodid  of  potassium  in  most 
cases.     If  sunstroke  is  the  cause,  treat  accordingly. 

Pachymeningitis  interna  may  extend  from  the  pia, 
or  may  extend  from  the  outer  layer  of  the  dura.  The  form 
known  as  heniatoina  of  the  dura  mater,  or  pachymeningitis 
interna  haemorrhagica,  may  arise  during  infectious  diseases 
(typhoid  fever  and  rheumatism),  in  persons  of  the  hemor- 
rhagic diathesis,  in  diseases  causing  atrophy  of  the  brain, 
in  chronic  diseases  of  the  heart  and  kidneys,  and  in  syph- 
ilitics.  Among  the  exciting  causes  are  traumatism,  in- 
flammation in  adjacent  parts,  and,  especially,  the  abuse  of 
alcohol.  In  this  disease  blood  is  extravasated  on  the  inner 
surface  of  the  dura.  Many  observers  do  not  class  hemor- 
rhagic pachymeningitis  as  inflammation,  but  regard  the 
hemorrhage  as  primary. 

The  symptoms  of  internal  pachymeningitis  are  very 
chronic,  are  not  characteristic,  and  may  be  absent.  They 
consist  usually  of  pei-sisteTif  headache  and  apoplectiform 
attacks,  with  contraction  of  the  pupil,  slow  pulse,  and  vom- 
iting. Choked  disk  is  not  infrequent,  localizing  symptoms 
"may  be  made  out,  and  coma  is  apt  to  arise. 

The  treatment  is  the  same  as  that  for  external  pachy- 
meningitis. 

Acute  leptomening'itis  is  a  purulent  inflammation  of 
the  soft  membranes  of  the  brain.  The  pathological  changes 
can  be  noted  in  the  pia  and  in  the  brain-substance.  The  brain 
is  edematous,  the  pia  purulent,  the  convolutions  are  flattened, 
the  ventricles  are  distended  with  fluid,  and  hemorrhages 
occur  into  the  brain-substance.  Pus  may  be  localized  upon 
the  pia,  but  it  is  usually  diffused  over  one  hemisphere  or 
over  both.  Various  organisms  may  be  found,  especially 
streptococci,  staphylococci,  and  diplococci.  In  some  cases  we 
find  the  bacillus  pyocyaneus  or  the  bacillus  pyocyaneus 
foetidus,  which  is  identical  with  the  colon  bacillus  and  with 
the  bacillus  meningitis  purulenta  (Park).  Saprophytic  or- 
ganisms are  occasionally  present.  This  disease  may  be  acute 
or  chronic,  and  a  severe  case  is  spoken  of  as  encephalitis. 
Secondary  leptomeningitis  is  apt  to  aflect  the  convexity  ; 
primary  leptomeningitis  is  apt  to  affect  the  base  (Hirt). 

The  causes  of  leptomeningitis  are  epidemic  cerebro- 
spinal fever,  tuberculosis,  acute  general  diseases  (pneu- 
monia, typhoid,  erysipelas,  and  rheumatism),  bone-diseases,. 
4:^ 


6/4  DISEASES  AND   INJURIES   OF  THE  HEAD. 

traumatisms,  middle-ear  disease,  syphilis,  and  sunstroke. 
The  tissues  of  the  pia  and  the  cerebrospinal  fluid  con- 
tain diplococci  identical  with  pneumococci.  Infection  may 
take  place  by  various  avenues.  It  may  pass  from  the  nose 
by  way  of  the  Eustachian  tube  to  the  ear,  or  from  the  nose 
to  the  frontal  sinus  or  ethmoid  sinuses  (Hirt),  and  from 
these  situations  to  the  brain.  It  may  pass  from  the  middle 
ear  or  mastoid  to  the  membranes  of  the  brain.  In  fractures 
at  the  base  the  organisms  enter  by  way  of  the  phaiynx  and 
the  Eustachian  tube,  or  the  ear.  The  symptoms  of  acute 
leptomeningitis  are  violent  headache  persisting  during  delir- 
ium, flushing  of  the  face,  rigidity  of  the  neck,  cerebral  vom- 
iting, a  slow  pulse,  elevated  temperature,  photophobia,  con- 
traction of  the  pupils,  intolerance  of  sound,  hyperesthesia 
of  the  skin  and  muscles,  and  delirium  passing  into  stupor 
and  coma.  A  chill  or  a  succession  of  chills  may  occur. 
Choked  disk,  strabismus,  and  nystagmus  are  not  unusual. 
Convulsions  or  paralyses  may  occur.  Death  is  the  rule 
within  one  week.  The  treatm.ent  usually  consists  of  purga- 
tion with  calomel ;  bleeding  behind  the  mastoid  processes  ; 
cold  to  the  head ;  warm  baths  with  cold  affusions  to  the 
head ;  iodid  of  potassium,  bromid  of  potassium,  or  morphin 
for  vomiting  and  headache.  Some  surgeons  trephine  in 
order  to  relieve  pressure  and  to  give  exit  to  inflammatory 
products,  and  this  procedure  should  be  employed.  It  gives 
some  hope  of  recovery,  and  the  usually  adopted  medical 
treatment  is  practically  useless ;  should  the  patient  recover, 
he  is  guarded  for  a  long  time  from  physical  exertion,  mental 
excitement,  worry,  irritation,  constipation,  and  insomnia. 

Chronic  I<eptomeningitis  (or  Encephalitis).  —  The 
causes  of  chronic  leptomeningitis  are  the  same  as  those  of 
the  acute  form.  If  traumatism  is  the  cause,  the  inflamma- 
tion arises  at  a  later  period  than  it  would  in  acute  encepha- 
litis. The  symptoms  of  concussion  follow  a  head-injury. 
Days,  or  even  weeks,  after  the  accident,  a  series  of  symp- 
toms occur — namely  :  localized  pain  at  the  seat  of  injury, 
often  accentuated  by  tapping;  listlessness;  irritability;  apathy 
regarding  business  affairs  and  home  obligations,  or  profound 
depression  and  hypochondria  with  inability  to  attend  to 
business.  Choked  disk  may  exist.  In  any  case  acute  en- 
cephalitis may  arise,  with  or  without  a  chill.  The  treatment 
of  this  disease  is  symptomatic  unless  local  .symptoms  exist. 
Always  operate  if  localizing  symptoms  are  found.  Intense 
local  pain  justifies  trephining. 

Tubercular  Meningitis  (Acute  Hydrocephalus  ;  Water 


MENINGITIS.  675 

on  the  Brain). — This  inflammatory  condition  is  due  to  the 
bacilh  of  tuberculosis.  In  a  child  affected  with  meningitis  there 
is  often  a  record  of  a  fall,  the  injury  acting  as  an  exciting  cause 
by  establishing  an  area  of  least  resistance.  Prodromal  symp- 
toms are  common  (restlessness,  irritability,  anorexia,  change 
of  character).  The  disease  begins  with  a  convulsion  or  with 
headache,  fever,  and  vomiting  (Osier),  the  child  cries  out 
from  pain  (the  hydrencephalic  cry),  and  the  bowels  are  con- 
stipated. The  pulse  is  rapid  in  the  beginning,  but  later  be- 
comes slow  and  irregular.  The  pupils  are  contracted,  there 
is  muscular  twitching,  and  the  sleep  is  impaired.  The  tem- 
perature is  about  103°.  In  the  second  period  of  the  disease 
the  vomiting  ceases,  constipation  becomes  more  marked,  the 
belly  retracts,  headache  is  not  so  violent,  and  the  patient 
lies  in  a  soporose  condition  interspersed  with  episodes  of 
delirium.  In  this  stage  the  pupils  dilate  and  are  often  un- 
equal, the  head  is  retracted,  convulsions  occur  or  limited 
rigidity  is  noted,  the  respirations  are  sighing,  and  if  a  finger- 
nail is  drawn  along  the  skin,  a  red  line  develops  (the  tdcJie 
ccrcbralc,  due  to  vasomotor  paresis).  Squint  and  conse- 
quent double  vision  are  usual.  In  the  last  stage  coma  be- 
comes absolute  and  general  convulsions  or  limited  spasms 
are  apt  to  occur.  Optic  neuritis  exists,  and  the  child  passes 
to  death  along  a  road  identical  with  that  of  typhoid  collapse. 
In  some  cases  the  examination  of  cerebrospinal  fluid  with- 
drawn by  lumbar  puncture  throws  light  upon  the  diagnosis. 
In  children  the  base  is  usually  involved,  and  the  disease  is 
apt  to  last  from  two  to  four  weeks  ;  in  adults  the  convexity 
of  the  brain  is  usually  involved,  and  death  is  apt  to  occur 
in  a  few  days. 

The  treatment  is  like  that  for  traumatic  meningitis. 

Abscess  of  the  brain  is  a  localized  collection  of  pus. 
The  organisms  found  are  noted  upon  page  673  (Acute 
Leptomeningitis).  The  causes  are  suppurative  otitis  media 
(in  half  of  all  the  cases),  fracture  of  the  skull,  concussion 
of  the  brain,  and  general  septic  diseases.  A  tubercular 
mass  may  caseate  (tubercular  abscess).  The  abscess  may 
be  between  the  dura  and  skull  (extradural),  adhesions 
forming  and  preventing  a  general  leptomeningitis,  between 
the  dura  and  brain  (subdural),  or  in  the  brain-substance 
(cerebral  or  cerebellar).  Leptomeningitis  may  arise  be- 
cause no  adhesions  form,  because  septic  clot  forms  in  veins 
or  sinuses,  or  because  infected  blood  regurgitates  in  sinuses 
(Park).  A  traumatic  abscess  is  generally  beneath  the  area 
to  which  the  traumatism  was  applied,  but  it  may  be  on  the 


676  DISEASES  AND   INJURIES   OF  THE   HEAD. 

opposite  side.  The  infection  may  begin  in  the  nose  (page 
668),  the  orbit,  or  the  middle  ear.  Roswell  Park  says  in- 
fection may  pass  along  blood-vessels,  lymph-vessels,  nerve- 
sheaths,  or  the  prolongations  of  the  membranes  which  extend 
outside  of  the  skull.  An  acute  inflammation  of  the  middle 
ear  rarely  causes  abscess,  because  an  acute  inflammation  in 
sound  tissues  causes  the  formation  of  granulation-tissue, 
which  acts  as  a  barrier  to  infection.  Chronic  inflammation 
of  the  middle  ear  is  the  most  frequent  cause  of  abscess.  Park 
tells  us  if  the  roof  of  the  tympanum  is  involved,  it  is  per- 
forated and  abscess  of  the  middle  fossa  ensues;  if  the  roof  of 
the  tympanum  is  perforated  toward  the  mastoid  antrum,  the 
abscess  arises  in  the  temporosphenoidal  lobe  ;  if  the  perfora- 
tion is  toward  the  sigmoid  groove,  the  abscess  forms  in  the 
cerebellum.^ 

Symptoms  of  Abscess  of  the  Cerebral  Substance. — 
The  symptoms  due  to  pus-formation  are  as  follows  :  there 
may  be  an  initial  rise  of  temperature,  but  (except  in  extra- 
dural abscess)  the  temperature  quickly  becomes  normal  or 
subnormal.  Toward  the  end  of  the  case  the  temperature 
may  rise  and  the  fever  become  linked  with  delirium. 
Surface  elevation  of  temperature  over  the  seat  of  the  ab- 
scess is  occasionally  observed.  A  chill  may  or  may  not 
occur.  Anorexia  and  vomiting  are  present.  Urinary 
chlorids  are  diminished  and  the  phosphates  are  increased 
(Somerville).  Symptoms  due  to  pressure  are — headache 
(which  at  first  is  general,  then  local,  and  grows  worse 
later  in  the  case,  and  exists  even  in  delirium  :  this  fact  dis- 
tinguishes it  from  the  headache  of  fever,  which  ceases  in 
delirium) ;  pulse  is  very  slow ;  respiration  tends  to  the 
Cheyne-Stokes  type ;  drowsiness  lapses  into  stupor  and 
stupor  passes  into  coma ;  paralysis  of  the  sphincters  takes 
place;  convulsions  are  common ;  sensation  is  rarely  impaired; 
and  paralysis  of  the  basal  nerves  may  occur  (third  and  sixth 
especially).  The  pupil  on  the  same  side  as  the  abscess  is 
dilated  and  fixed.  Choked  disk  is  not  invariably  found ; 
if  it  is  unilateral,  it  is  on  the  same  side  as  the  abscess  ;  if 
it  is  bilateral,  it  is  more  marked  on  the  same  side  as  the 
abscess.  Localizing  symptoms,  spasmodic  and  paralytic, 
depend  upon  the  center  which  is  irritated  or  destroyed.. 
In  cerebellar  abscess  there  are  vertigo,  vomiting,  occipital 
headache,  rigidity  of  the  post-cervical  muscles,  and  inco- 
ordination.    Choked  disk  is  often  absent. 

Meningitis  arises  soon  after  an  accident ;  an  abscess,  more 

^  Park,  in  Chicago  Med.  Record,  Feb.,  1S95. 


.^1BSC£SS   OF   THE   BRAIN.  6jJ 

than  a  week,  often  many  weeks,  after  an  accident.  Menin- 
gitis presents  high  temperature  and  the  general  symptoms 
before  outHned.  Mastoid  disease  may  occasion  cerebral 
symptoms  without  abscess,  or  it  may  cause  abscess.  In 
sitnis-thronibosis  there  is  septic  temperature,  the  veins  of  the 
face  and  neck  are  enlarged,  and  a  clot  can  usually  be  felt 
in  the  jugular.  A  tumor  grows  slowly,  usually  presents 
almost  from  the  start  distant  localizing  symptoms,  and 
double  choked  disk  is  frequently  present.  In  tumor  the 
temperature  is  apt  to  be  normal. 

Treatment. — If  abscess  is  due  to  ear  disease  with  implica- 
tion of  the  mastoid  cells,  at  once  open  the  mastoid,  and  after 
this  proceed  to  trephine  the  skull  in  order  to  reach  the  ab- 
scess. In  any  case,  if  symptoms  of  abscess  exist,  trephine 
the  skull  at  once.  If  localizing  symptoms  are  present,  open 
over  the  suspected  region.  If  localizing  symptoms  are  not 
present  and  the  cause  is  ear  disease,  trephine  at  Barker's 
point  (Fig.  246).  If  no  pus  is  found  between  the  bone  and 
dura,  open  the  membrane.  When  the  dura  is  opened,  if  the 
abscess  is  subdural  pus  will  be  evacuated  ;  if  the  abscess  is 
in  the  brain-substance,  the  brain  will  bulge  very  much  and 
will  not  be  seen  to  pulsate.  A  grooved  director  is  plunged 
into  the  brain,  in  the  direction  of  the  abscess,  for  two  or  two 
and  a  half  inches  (Keen).  If  pus  is  not  found,  withdraw  the 
director  and  introduce  it  at  another  point.  When  pus  is 
discovered  incise  the  brain  with  a  knife,  enlarge  the  open- 
ing by  inserting  a  closed  pair  of  forceps  and  withdrawing 
the  instrument  with  the  blades  open.  Scrape  away  the 
granulation-tissue  lining  the  abscess-cavity,  irrigate  with  hot 
salt  solution,  and  introduce  a  rubber  drainage-tube  ;  stitch 
the  dura,  but  leave  an  ample  opening  for  the  tube ;  bring  the 
tube  out  through  a  button-hole  in  the  scalp,  and  after  the 
first  two  days  pull  the  tube  out  a  little  every  day  and  cut 
off  a  piece.  If  the  first  trephining  does  not  find  pus,  trephine 
again  at  another  point.  In  cerebellar  abscess  make  a  flap 
with  the  base  up,  and  trephine  or  gouge  away  the  bone  just 
below  the  line  of  the  lateral  sinus.  Puncture  the  brain  as 
for  cerebral  abscess. 

Brain  Disease  from  Suppurative  Ear  Disease. — 
Chronic  disease  of  the  middle  ear  is  apt  to  destro}-  the  bone 
between  the  tympanum  and  the  middle  fossa  of  the  skull, 
and  thus  produce  meningitis,  thrombosis  of  the  petrosal  or 
lateral  sinuses,  abscess  of  the  temporosphenoidal  lobe  or  of 
the  cerebellum,  or  extradural  abscess.  Chronic  otitis  media 
also   induces   inflammation    or   suppuration   of  the   mastoid 


6/8  DISEASES  AND   INJURIES   OF   THE   HEAD. 

cells  (empyema  of  mastoid).  Pus  in  the  mastoid  may  dis- 
charge itself  into  the  middle  ear,  and  from  this  point  into 
the  external  auditory  canal,  through  a  perforation  in  the 
drum-membrane  (especially  in  acute  cases).  In  some  cases 
the  pus  becomes  blocked  up  within  the  mastoid  process. 
Pus  in  the  mastoid  may  after  a  time  break  into  the  cavity 
of  the  cranium  or  into  the  lateral  sinus,  or  may  find  its 
way  externally  and  open  into  the  sheaths  of  muscles  aris- 
ing from  the  mastoid.  It  not  unusually  opens  into  the 
sheath  of  the  digastric  muscle  (Bezold's  abscess).  These 
facts  teach  the  surgeon  that  chronic  ear  disease  should  never 
be  neglected,  but  should,  if  possible,  receive  the  closest  atten- 
tion of  the  specialist.  If  no  perforation  exists  in  the  drum, 
the  surgeon  must  make  one.  In  ordinary  cases  cleanHness 
and  antisepsis  are  sufficient,  the  ear  being  syringed  every 
day  with  a  warm  2  per  cent,  solution  of  common  salt.  If 
only  a  small  drum-perforation  exists,  10  drops  of  pure  alco- 
hol or  of  corrosive-sublimate  solution  (i  :  5000)  are  dropped 
into  the  ear  daily;  but  if  a  large  drum-perforation  exists,  boric 
acid  and  iodoform  (7  to  i)  are  insufflated.  Never  inject  alum. 
A  strong  silver  solution  is  not  safe ;  if  it  is  used,  wash  the 
ear  out  afterward  with  warm  salt  water.  If  granulations  or 
polypi  exist,  they  must  be  removed  (Burnett).  Some  cases 
require  the  removal  of  the  drum-membrane  and  the  ossicles 
of  the  ear.  Many  cases  of  mastoid  necrosis  are  due  to  tuber- 
culosis. If  headache,  vomiting,  and  mastoid  tenderness  exist, 
open  the  mastoid  (see  Operations),  in  order  to  prevent  ab- 
scess of  the  brain.  In  acute  otitis  media  it  is  very  rarely 
necessary  to  open  the  mastoid.  The  middle  ear  is  on  a 
lower  level  than  the  antrum  of  the  mastoid,  and  in  most 
acute  cases  both  the  middle  ear  and  mastoid  cells  drain  safely 
through  a  drum-perforation.  Because  a  man  has  chronic 
otitis  media  it  is  by  no  means  always  necessary  to  trephine 
the  mastoid.  In  many  cases  removal  of  the  ossicles  and 
drum-membrane  effects  a  cure.  In  chronic  otitis  media,  even 
if  the  mastoid  is  trephined,  the  ossicles  and  membrane  ought 
to  be  removed. 

Cerebral  abscess  from  ear  disease  is  almost  always 
in  the  temporosphenoidal  lobe,  but  may  arise  in  the  cere- 
bellum. The  symptoms  are  a  transient  rise  of  temperature 
followed  by  a  subnormal  temperature ;  vomiting ;  mastoid, 
frontal,  and  temporal  pain.  The  mind  is  dull,  and  stupor 
arises  which  passes  into  coma ;  the  bow^els  are  constipated ; 
choked  disk  may  be  present ;  and  convulsions  or  spasms  or 
paralyses  may  exist.     Trephine  and  clean  out  the  mastoid. 


IXFECTIVE   SIXCS-THROMBOSIS.  679 

and  asepticize  (see  Operations  upon  the  Skull  and  Brain). 
Trephine  at  Barker's  point,  one  and  one-fourth  inches  be- 
hind, and  the  same  distance  above,  the  middle  of  the  ex- 
ternal auditory  meatus.  If  pus  is  not  found,  open  the  cere- 
bellum. 

Extradural  Abscess. — The  eye-symptoms  and  pain  are 
the  same  in  this  as  in  cerebral  or  subdural  abscess,  but  the 
temperature  is  different,  rising  to  103°  or  104°  F.  There  is 
often  considerable  tenderness  above  and  behind  the  mastoid. 
In  extradural  abscess  following  disease  of  the  middle  ear, 
trephine  and  clean  out  the  mastoid ;  follow  up  a  bone-sinus 
to  the  abscess,  rongeur  away  the  bone,  being  careful  to  avoid 
injuring  the  lateral  sinus,  curet,  irrigate,  and  drain. 

Infective  Sinus-thrombosis. — Any  sinus  may  be  at- 
tacked. In  erysipelas  of  the  scalp,  septic  clots  may  form 
in  the  veins  which  pass  through  the  bone  and  reach  the 
longitudinal  sinus.  Infective  thrombosis  of  the  superior 
longitudinal  sinus  is  thus  produced. 

In  carbuncle  of  the  lip  and  orbital  suppuration  the  cavern- 
ous sinus  may  become  involved. 

In  caries  of  the  basilar  portion  of  the  occipital  bone  the 
circular  sinus  or  the  cavernous  sinus  may  suffer.  In  caries 
of  the  petrous  portion  of  the  temporal  bone,  and  in  suppura- 
tion of  the  middle  ear  and  mastoid  .process,  infective  throm- 
bosis of  the  lateral  sinus  may  occur. 

In  any  case  the  symptoms  are  those  of  pyemia.  The 
lateral  sinus  is  the  one  most  frequently  attacked.  In  infective 
thrombosis  of  the  lateral  sinus  there  is  usually  a  history  of 
an  old  discharge  from  the  ear. 

The  symptoms  of  this  disease  present  a  histoiy  of  chronic 
ear  disease.  Headache  and  pain  over  the  sinus  arise  ;  violent 
rigors  occur;  and  the  temperature  rises  and  fluctuates 
greatly.  The  patient  is  nauseated,  labors  under  vertigo,  is 
very  restless  ;  is  dull  and  stupid,  sometimes  delirious ;  and 
the  muscles  of  the  neck  are  stiff  Tenderness  and  marked 
edema  are  detected  over  the  mastoid.  When  the  clot  extends 
into  the  jugular  vein  there  is  pain  on  moving  the  head  and 
on  swallowing,  the  cervical  glands  are  swollen,  and  a  clot 
may  be  felt  in  the  neck.  Exophthalmos  and  swelling  of  the 
eyelids  point  to  involvement  of  the  cavernous  sinus  in  the  proc- 
ess. Choked  disk  exists  in  about  half  of  all  cases.  There 
is  often  a  profuse  discharge  of  pus  from  the  ear,  but  in  some 
cases  the  discharge  is  found  to  have  abated  or  ceased.  In 
early  cases  there  is  thrombosis  of  the  lateral  sinus  alone,  or 
of  the  lateral  sinus    and  jugular  vein.     In  advanced  cases 


68o  DISEASES  AND   INJURIES   OF   THE   HEAD. 

other  sinuses  become  involved  (superior  petrosal,  inferior 
petrosal,  both  cavernous,  the  lateral  sinus  of  the  opposite 
side,  the  ophthalmic  veins,  and  the  torcular  Herophili).  A 
patient  with  sinus-thrombosis  is  in  great  danger  of  devel- 
oping pulmonary  metastasis  and  septic  meningitis  (Jansen). 
Septic  meningitis  is  accompanied  by  abscess  about  the  sinus. 

The  prognosis  largely  depends  upon  early  recognition. 
The  surgeon  should  open  a  mastoid  before  sinus-thrombosis 
arises,  and  should  evacuate  a  perisinous  abscess  before  a  clot 
forms  in  the  sinus,  or  at  least  before  that  clot  becomes  septic 
(Jansen). 

Treatment. — Infective  thrombosis  of  the  lateral  sinus  is 
treated  as  follows  :  open  and  clean  out  the  mastoid,  and 
expose  the  sinus  by  the  use  of  the  chisel  or  rongeur  (Fig. 
246).  Open  the  sinus,  and  if  a  clot  is  found  to  exist  cut  away 
the  wall  of  the  sinus.  Introduce  a  small  spoon  into  the  sinus 
and  carry  it  toward  the  torcular  Herophili,  and  scrape  away 
the  clot  until  blood  flows.  Arrest  hemorrhage  by  plugging  a 
piece  of  iodoform  gauze  into  the  wound  and  toward  the  tor- 
cular. Jansen  opposes  removing  the  entire  clot  toward  the 
jugular,  and  does  not  tie  the  jugular,  believing  that  to  do  so 
increases  the  danger  of  thrombosis  of  the  inferior  petrosal 
and  cavernous  sinuses.  Influenced  by  these  views,  Jansen 
removes  the  soft  clot,  but  does  not  disturb  the  solid  clot 
toward  the  heart.  Most  surgeons  differ  with  him,  and  after 
opening  the  sinus,  turning  out  the  clot  and  packing,  proceed 
to  ligate  the  jugular  vein  at  the  level  of  the  cricoid  cartilage. 
If,  after  this  operation,  the  clot  in  the  jugular  becomes  septic, 
incise  the  vein  up  to  the  base  of  the  skull  and  pack.  It  is 
obviously  futile  to  do  any  operation  if  pulmonary  metastasis 
has  taken  place,  although  in  a  recent  case  in  the  Jefferson 
Medical  College  Hospital  the  patient  recovered  after  opera- 
tion in  spite  of  the  fact  that  endocarditis  had  developed. 

Until  recently  it  was  thought  that  the  lateral  sinus  was 
the  only  sinus  which  should  be  attacked  surgically,  but  in  a 
recent  case  Knapp  of  New  York  requested  Hartley  to 
remove  from  the  cavernous  sinus  a  clot  which  was  causing 
blindness.  The  operation  was  successfully  executed  by 
Hartley,  the  incision  being  the  same  as  is  employed  to  reach 
a  Gasserian  ganglion  in  the  Hartley-Krause  operation. 

Intracranial  tumors  may  be  true  neoplasms,  may  be 
of  parasitic  origin,  may  result  from  injury,  may  be  tubercu- 
lar or  syphilitic.  Among  these  tumors  are  papillomata, 
gliomata,  sarcomata,  choleostomata,  fibromata,  psammomata, 
myxomata,  osteomata,  etc.  (see  Tumors).     Cysts  sometimes 


INTRACRANIAL    TUMORS.  68 1 

occur.  The  symptoms  are  diffuse  and  local,  and  are  simi- 
lar in  many  particulars  to  the  symptoms  of  some  other 
lesions.  Among  the  symptoms  of  tumor  are  headache, 
slow  speech,  stupor  or  coma,  slow  pulse,  pain  on  percussion 
of  the  cranium,  vertigo,  vomiting,  epileptic  convulsions, 
double  choked  disk,  partial  or  complete  blindness,  extensive 
or  limited  paralyses,  paralysis  of  the  face,  the  eye-muscles,  or 
the  limbs,  zones  of  anesthesia  and  aphasia,  word-deafness, 
word-blindness,  agraphia,  inco-ordination,  and  mental  disturb- 
ances. The  situation  of  a  turriOr  is  determined  from  localizing 
symptoms,  their  mode  of  onset  and  manner  of  combination. 
In  some  cases  the  symptoms  are  not  characteristic,  and  in 
some  cases  there  are  no  localizing  symptoms.  The  nature 
of  the  tumor,  its  depth,  and  whether  it  is  single,  and  if  other 
tumors  exits,  is,  if  possible,  determined.  Localizing  symp- 
toms may  be  due  to  irritation  or  destruction  of  func- 
tionating power.  Irjitation  causes  spasm  and  destruction 
induces  paralysis.  Convulsions  which  are  local  or  which 
begin  locally  are  known  as  Jacksonian  epilepsy.  A  local 
convulsion  points  to  an  irritative  lesion  of,  or  immediately 
adjacent  to,  the  center  which  presides  over  the  rnus.cular 
movements  of  the  part  convulsed.  Local  paralysis  points 
to  a  destructive  lesion  of  the  center  which  presides  over  the 
movements  of  the  paralyzed  part.  In  some  cases  a  center 
is~  damaged  and  the  muscular  movements  it  controls  are 
paralyzed,  but  the  adjacent  brain-areas  are  irritated  and  the 
muscles  they  represent  are  attacked  with  spasms.  In  some 
cases  an  apparently  paralyzed  part  becomes  convulsed,  the 
center  not  being  completely  destroyed  and  sudden  hyperemia 
serving  to  awaken  spasm.  Always  note  the  order  of  inva- 
sion of  different  regions  and  observe  if  spasm  is  followed  by 
muscular  weakness  or  anesthesia. 

I.  Lesions  in  the  Cortical  Motor  Area. — An  irritative 
lesion  of  the  lower  third  of  this  area  causes  spasm  of  the 
opposite  side  of  the  face,  angle  of  mouth,  or  tongue;  and 
this  condition  is  often  associated  with  tingling  (Osier).  The 
spasm  may  remain  limited  or  may  extend  widely,  and  may 
even  become  general.  Tumors  of  the  third  frontal  convo- 
lution of  the  left  side  cause  rnotqr  aphasia..  An  irritative 
lesion  of  the  middFe  "third  of  the  cortical  area  causes  spasm, 
Avhich  is  limited  to  or  begins  in  the  fingers,  thumb,  wrist^or 
shoulder  (Osier).  An  irritative  lesion  oT  tHe  upper  third  of 
the  cortical  motor  area  causes  spasm,  which  is  limited  to  or 
begins  in  the  toes,  ankle^  leg,  or  hip.  If  such  lesions  exist 
an  aura  is  occasionally  felt  in  the  affected  region  before  the 


682  DISEASES  AND    INJURIES   OF   THE   HEAD. 

spasm  begins,  and  there  is  often  numbness  after  the  spasm. 
Destructive  lesions  of  the  motor  area  cause  local  paralysis, 
which  may  be  preceded  by  local  spasm  of  the  same  parts, 
and  is  often  associated  with  local  spasm  of  other  parts. 

2.  Tumors  of  the  prefrontal  region  give  no  localizing 
symptoms,  but  produce  general  symptoms.  Mental  disord^r.s 
are  apt  to  occur.  As  the  tumor  grows  it  may  subsequently 
involve  the  motor  region. 

3.  Tumors  of  the  parieto-occipital  lobe  may  occupy  a 
silent  region  of  this  lobe.  There  may  be  blindness  or  para- 
phasia when  the  angular  gyrus  is  affected. 

4.  Tumors  of  the  occipital  lobe  produce  homonymous 
hemianopsia. 

'  5.  Tumors  of  the  temporosphenoidal  lobe  frequently 
produce  no  symptoms.  Tumors  in  the  left  lobe  may  cause 
deafness. 

6.  Tumors  of  any  size  in  or  about  the  corpus  striatum 
cause  hemiplegia  by  pressure  upon  the  internal  capsule. 
Pressure  upon  the  optic  thalamus  produces  hemianopsia  and 
hemianesthesia.  Growths  near  the  basal  ganghon  produce 
intense  optic  neuritis  and  early  pressure  because  of  distention 
of  the  ventricles.  Osier  tells  us  that  tumors  of  the  corpora 
quadrigemina  are  apt  to  involve  the  crura,  and  later  the  third 
nerve.  Ocular  symptoms  are  always  present  (loss  of  pupillary 
reflex  and  nystagmu.s).  If  the  third  nerve  is  involved,  there 
are  paralysis  of  the  motor  oculi  area  on  the  side  of  the  lesion 
(external  strabismus,  dilated  pupil,  and  drop  lid),  and  hemi- 
plegia  of  the  opposite  side  of  the  body  from  pressure  upon 
the  crus.     This  condition  is  a  form  of  crossed  paralysis. 

7.  Tumors  of  the  Pons. — Pontine  lesions  produce  symp- 
toms by  pressure  upon  the  particular  nerves  which  come 
from  this  region,  with  or  without  the  evidences  of  pressure 
upon  the  motor  path.  Forms  of  crossed  paralysis  may 
exist.  Lesions  in  the  lower  half  of  the  pons  may  affect  the 
fifth,  sixth,  and  seventh  nerves  on  the  side  of  the  lesion,  and 
the  limbs  on  the  opposite  side.  The  auditory  nerve  may  be 
involved  in  the  lesion.  In  crossed  paralysis  the  face  on  the 
side  of  the  limb  paralyzed  is  usually  not  affected,  but  in 
extensive  tumors  it  may  be  paralyzed.  Conjugate  deviation 
may  occur  away  from  \.\\q  facial  paralysis.  In  tumors  of  the 
upper  part  of  the  pons  the  pupils  may  be  first  contracted 
from  irritation  of  the  third  nuclei,  and  later  dilated  from 
destruction  of  these  nuclei.  Anesthesia  as  a  result  of  pon- 
tine tumors  is  not  nearly  so  common  as  is  motor  paralysis,, 
and  convulsions  are  rare. 


INTRACRANIAL    TUMORS.  683 

8.  Tumors  of  the  Medulla. — An  extensive  lesion  inevit- 
ably causes  death.  Cranial  nerves  only  may  be  involved, 
but  crossed  paralysis  may  take  place.  Vomiting  is  common, 
retraction  of  head  is  not  unusual,  respiratory  and  circulatory 
disturbances  and  dysphagia  are  frequently  noted;  sometimes 
there  is  numbness,  and  occasionally  there  are  convulsions  ; 
usually  there  is  inco-ordination,  because  of  pressure  upon 
the  cerebellum. 

9.  Tumors  of  the  Cerebellum. — Tinnors  of  the  middle 
peduncle  cause  sudden  uncontrollable  movements  of  the 
trunk,  either  toward  the  side  of  the  tumor  or  away  from  it. 
Vertigo  and  nystagmus  are  common.  SymptomiS  are  fre- 
quently complicated  by  evidences  of  pontine  disease 
proper. 

Tumors  of  the  middle  lobe  of  the  cerebellum  cause  a  sense 
of  lost  equilibrium  and  obvious  unsteadiness  in  attempting  to 
walk,  or  even  to  stand  (Gowers).  The  patient  has  a  ten- 
dency to  fall ;  there  are  giddiness  and  vorniting. 

Tumors  of  the  cerebellar  hemispheres  produce  no  localizing 
symptoms.  The  usual  unsteadiness  of  gait  is  due  to  pressure 
upon  the  middle  lobe  (Nothnagel).^ 

Treatment. — If  any  doubt  exists  as  to  the  nature  of  a  brain 
tumor,  give  the  patient  a  course  of  iodid  of  potassium,  and 
as  doubt  is  the  rule,  we  almost  invariably  administer  it.  Give 
at  first  in  small  amounts,  but  rapidly  increase  it  until  heroic 
doses  are  taken  (lOO  or  more  grains  a  day).  Mercury 
should  also  be  given  hypodermatically.  If  iodid  of  potas- 
sium and  mercury  relieve  the  symptoms,  operation  is  unnec- 
essary, although  it  may  be  demanded  later  in  order  to  remove 
an  irritant  scar.  If  antisyphilitic  treatment  fails,  the  ques- 
tion of  operation  must  be  considered.  In  many  cases  of 
undoubted  tumor  excision  for  cure  is  not  attempted  because 
of  the  absence  of  localizing  symptoms  or  because  of  the 
inaccessible  situation  of  the  growth.  Tumors  at  th£_±),a_se, 
tumors  of  the  pons  and  medulla,  of  the  corpus  cailosum,  of 
the  basal  ganglia,  of  the  deeper  parts  of  the  centr_umL_QiLale, 
are  irremovable  (Byrom  Bramwell).  Most  tumors  of  the 
cerebellum  should  not  be  attacked.  In  tumors  which  are 
very  "extensive  complete  removal  is  usually  out  of  the  ques- 
tion. There  is  no  use  in  removing  secondary  malignant 
tumors.  It  often  happens  that  the  brain  itself  (as  in  syphilis) 
is  so  extensively  diseased,  or  that  other  organs  (as  in  tuber- 
culosis) are  so  involved,  as  to  render  attempts  at  removal 

1  For  full  consideration  of  localizing  symptoms,  see  the  works  of  Gowers  and 
Osier,  which  have  been  freely  used  in  writing  the  above  section. 


684  DISEASES  AND   INJURIES    OF   THE   HEAD. 

futile.  Bramwell  tells  us  '  that  he  has  studied  eigthty-two 
cases  of  intracranial  tumors,  and  he  considers  that  in  only- 
five  of  them  could  the  tumor  have  been  entirely  removed. 
The  conclusion  is  that  though  some  tumors  of  the  brain  may 
be  successfully  removed,  extirpation  is  only  to  be  decided 
on  after  careful  study  of  all  the  indications  and  contraindica- 
tions offered  by  the  case.  The  fibromata  constitute  the  best 
cases  for  operation.  In  cases  not  operated  upon  it  may  be 
necessary  to  use  the  bromids  for  convulsions  and  morphin 
for  headache.  The  headache  is  often  benefited  by  purga- 
tives, courses  of  potassium  iodid,  the  ice-bag  to  the  head, 
and  the  applicatidn^of^a  hot  iron  to  the  nape  of  the  neck. 
Though  thorough  extirpation  is  feasible  in  but  few  cases, 
operation  should  often  be  performed  for  palliative  purposes. 
Grainger  Stewart,  Annandale,  Horsley,  Macewen,  and  Keen 
have  advocated  palliative  trephining  in  certain  cases. 

This  procedure  is  of  value  in  diminishing  excessive  intra- 
cranial pressure,  and  thus  relieving  headache  and  decreasing 
the  tendency  to  sudden  death  from  inhibition  of  the  heart 
or  respiratory  failure  (Hughlings  Jackson  and  Byrom  Bram- 
well). 

Palliative  trephining  may  relieve  optic  neuritis,  and  thus 
retard  or  prevent  atrophy  and  blindness.  Bramwell  asserts 
this  positively,  and  he  still  believes  that  excessive  intracere- 
bral pressure  is  an  important  element,  though  not  the  only 
element  in  neuritis. 

Most  cases  of  tumor  should  be  trephined  for  exploration ; 
in  some  cases  extirpation  may  be  performed  ;  in  most  cases  ex- 
tirpation is  impossible,  and  the  surgeon  must  be  content  with 
the  palliative  influence  of  trephining.  A  tumor  of  the  brain 
if  not  cured  by  antisyphilitic  treatment,  is  of  necessity  fatal 
if  un.operated  upon,  and  trephining  is  not  a  very  dangerous 
operation.  After  palliative  trephining,  make  an  attempt  to 
obtain  prolonged  drainage  of  cerebrospinal  fluid. 

Operative  Treatment  of  Epilepsy. — The  shock  of 
an  accident  or  a  general  concussion  may  establish  epilepsy, 
especially  in  those  predisposed  by  heredity  or  other  causes. 
Traumatic  epilepsy,  Le  Dentu  tells  us,^  may  be  due  to  : 
(i)  bone-fragments  from  skull-fracture;  (2)  outgrowths  of 
bone  due  to  tumor;  (3)  cicatrices  of  meninges  resulting  from 
laceration  of  membranes  by  bone-fragments ;  (4)  chronic 
meningitis  which  ends  in  sclerosis  of  membranes ;  (5) 
cysts    resulting  from  intracranial    hemorrhage  at  the  point 

^  Edin.  Med.  Jour.,  June,  1894. 
''■  La  Presse  medicale,  June  9,  1894. 


OPERATIVE    TREATMEXT  OF  EPILEPSY.  685 

of  fracture  ;  (6)  arterioxenous  aneur}-sm.  We  refer  here, 
in  speaking  of  traumatic  epilepsy,  purely  to  the  condition 
when  it  follows  a  head-injur\',  and  this  is  the  common 
meaning  of  the  term.  Remember  that  epilepsy,  as  shown  by 
Sachs,  may  follow  a  long-forgotten  injury.  When  epilepsy 
has  followed  traumatism  and  a  scar  exists  upon  the  scalp, 
excise  the  scar,  especially  if  it  is  tender  or  is  the  seat  of 
an  aura.  If,  on  lifting  the  scalp,  a  depression  of  bone  or  a 
disease  of  the  bone  is  manifest,  trephine  for  exploration, 
even  over  a  silent  area.  Trephining  in  epilepsy  may  disclose 
a  cyst,  a  dural  scar,  a  brain-scar,  a  depressed  portion  of  bone, 
or  eburnation  of  bone  from  osteitis  (Keen).  In  exploratory 
operations  for  epilepsy  alwaj's  open  the  dura.  When  the 
injury  is  over  a  known  motor  center  it  is  important  to  tre- 
phine. This  operation  is  especially  indicated  when  the  con- 
vulsions begin  in  the  muscles  of  this  center,  in  which  case 
it  is  proper  to  remove  the  center  after  trephining.  Remove 
all  sources  of  peripheral  irritation  (Briggs  reported  a  case  of 
epilepsy  in  which  there  were  distinct  skull-depression  and 
necrosis  of  the  tibia,  but  the  cure  of  the  necrosis  of  the  tibia 
arrested  the  convulsions).  If  epilepsy  arises  notwithstanding 
primary  trephining,  open  the  flap,  round  the  bony  edges  with 
a  rongeur,  and  cut  out  the  scar.^ 

These  operations  sometimes  seem  to  cure  epilepsy,  but  so, 
occasionally,  does  any  operation.  Wliite  records "  ninety 
trephinings  in  which,  though  no  cause  was  found  for  the 
epilepsy,  great  relief  followed,  and  two  cases  were  apparently 
cured ;  he  mentions  benefit  or  apparent  cure  following  tra- 
cheotomy, ligation  of  the  carotid  artery,  incision  of  the  scalp, 
etc.  The  same  effect  may  be  obtained  by  a  great  shock, 
high  fever,  the  administration  of  an  anesthetic,  or  an  acci- 
dent. The  fact  seems  to  be  that  any  operation,  by  means 
of  nervous  shock,  may  interrupt  the  epileptic  habit ;  but 
in  ordinary  operations  the  fits  tend  after  a  time  to  recur, 
and  soon  reach  their  old  standard  of  frequency.  In  the 
special  brain-operations  with  excision  of  obvious  lesions 
or  discharging  centers  the  fits  usually  recur,  but  they  will 
rarely  reach  the  old  standard  of  frequency,  and  will  be  more 
amenable  to  medical  treatment.  Bramwell  sa}-s  that  when 
traumatism  is  followed  by  epilepsy  and  the  epileptic  discharge 
starts  from  a  cortical  center  which  is  not  beneath  the  scar, 
trephine  first  at  the  seat  of  injury,  and  if  no  lesion  is  met 

'  The  author,  in  Hare's  System  of  Practical  Therapeutics. 
^  "  The  Supposed  Curative  Effects  of  Operations  per  se,"  Annals  of  Surgery, 
August  and  September,  1891. 


686  DISEASES  AND  INJURIES   OF  THE  HEAD. 

with  trephine  over  the  discharging  center.  In  epilepsy  the 
fits  are  to  be  studied  by  a  competent  observer  (Keen)  and, 
if  focal  epilepsy  or  Jacksonian  epilepsy  exist,  and  treatment 
by  drugs  has  failed,  trephining  is  to  be  performed  over  the 
diseased  center  and  the  explosive  focus  is  to  be  located  by 
an  electric  current  and  removed.  Keen,  Horsley,  Nancrede, 
Macewen,  and  others  practise  this,  but  hope  for  improve- 
ment rather  than  expect  cure.  This  operation  causes  paraly- 
sis, but  the  paralysis  is  rarel^^  permanent,  except,  perhaps,  of 
the  finer  movements. 

In  non-traumatic  chronic  epilepsy  without  localizing  symp- 
toms trephining  is  not  justifiable  unless  persistent  headache 
calls  for  it  as  a  means  of  relief  from  intracranial  pressure. 
Annandale  has  recently  advised  us  to  consider  experimental 
operation  in  such  cases  when  the  drug-treatment  has  failed 
and  when  the  patient's  condition  seems  hopeless.  He  says 
there  is  no  chance  of  improvement  without  operation,  and 
operation  may  possibly  disclose  a  removable  lesion.^  After 
trephining  for  epilepsy  five  years  should  elapse  without  a 
convulsion  before  cure  is  reasonably  assured ;  and  if  con- 
vulsions arise,  they  must  at  once  be  met  by  medical  treat- 
ment. A  man  having  once  had  a  convulsion  may  at  any 
time  have  others ;  hence  he  should  always  be  watched.  It 
is  not  unusual  for  a  few  convulsions  to  occur  soon  after  an 
operation  for  epilepsy,  and  then  to  cease  for  a  considerable 
time.  These  early  fits  result  from  habit.  Among  the  oper- 
ative procedures  suggested  for  the  treatment  of  epilepsy 
may  be  mentioned  circumcision,  clitoridectomy,  ocular  ten- 
otomy, ligation  of  the  vertebral  arteries,  removal  of  the  cer- 
vical ganglia  of  the  sympathetic  (Alexander,  Jonnesco, 
Jaboulay),  and  the  actual  cautery  to  the  head  (Fere). 

Operations  on  the  Skull  and  Brain. — Trephining- 
(in  a  fracture  of  the  skull). — Shave  the  scalp,  scrub  it  with 
ethereal  soap  and  sterile  water,  wash  it  with  sterile  water 
and  then  with  alcohol  or  ether,  scrub  with  a  brush  wet 
with  corrosive-sublimate  solution  (i  :  looo),  and  wrap  the 
scalp  in  wet  corrosive-sublimate  gauze  (i  :  200o).  The 
instruments  required  are  a  scalpel,  a  dissector,  hemo- 
static, dissecting,  and  toothed  forceps,  trephines  of  several 
sizes  (Figs.  244,  245),  a  periosteum-elevator,  Hey's  saw, 
rongeur  forceps,  a  bone-elevator,  a  dural  separator,  a  tenac- 
ulum, small  curved  and  large  curved  Hagedorn  needles, 
and  a  needle-holder,  catgut,  fine  silk,  silkworm-gut,  and 
Horsley's  wax.     Provide  a  sand  pillow.     The  patient  should 

'  Edin.  Med.  Jour.,  April,  1894. 


OPEHATJOXS   OX   THE   SKULL   AND   BRAIX. 


687 


be  anesthetiz.ed  unless  he  is  unconscious,  and  is  placed  upon 
his  back  with  the  shoulders  a  little  raised.  A  sand  pillow- 
is  placed  under  the  neck,  and  his  head  is  turned  away  from 
the  side  to  be  operated  upon.  The  position  of  the  surgeon 
is  such  that  the  patient's  head  is  a  little  to  his  left.  A  large 
semilunar  incision  is  made  with  the  base  down,  which  incision 
goes  through  the  periosteum,  and  the  flap  is  lifted.  The 
bleeding  vessels  of  the  flap  are  caught  with  forceps.  The 
fracture  is  sought  for  and  found.  The  pin  of  the  trephine  is 
projected  beyond  the  crown  and  is  set  upon  sound  bone,  the 
crown  overhanging  the  line  or  edge  of  the  fracture.  The 
surgeon  tries  to  avoid  the  region  of  a  sinus  or  large  arter\'. 
A  gutter  is  cut  in  the  bone,  the  pin  of  the  instrument  is 
withdrawn,  and  the  trephining  is  completed.  In  going 
through  the  diploe  bleeding  is   copious.       The   inner  table 


Fig.  244. — Gait's  conical  trephine. 


Fig.  245. — Crown  trephine. 

feels  ven,-  dense.  Stop  from  time  to  time,  clean  out  th.e 
gutter  in  the  bone  with  the  dissector,  and  try  the  bone  with 
an  elevator  to  see  if  it  is  loose.  When  the  fragment  is  loose 
enough,  prv^  it  out.  If  the  surgeon  desires  to  replace  the 
button,  hand  it  to  an  assistant,  who  places  it  at  once  in  a 
bowl  of  solution  of  corrosive  sublimate  (i  :  2000),  kept  warm 
by  standing  in  a  basin  of  water  at  105°  F.,  or  who  puts  it 
in  warm  carbolized  towels  or  in  warm  normal  salt  solution. 
The  edges  of  the  opening  should  be  rounded  with  a  rongeur 
and  the  bone,  if  depressed,  must  be  elevated.  Sometimes  it 
may  be  necessary  to  remove  splinters  and  fragments  of  bone. 
After  removing  the  fragments  the  edges  of  the  opening 
should  be  smoothed  by  the  use  of  the  rongeur  forceps. 
The  dura  should  be  examined  to  see  if  injur}'  exists,  and 
hemorrhage  must  be  stopped.  Bleeding  from  the  dura  is 
arrested  by  passing  a   ligature  of  silk   or  catgut  under  the 


688  DISEASES  AND   INJURIES    OF   THE   HEAD. 

vessel  on  each  side  of  the  wound,  and  tying  the  Hgatures. 
This  is  effected  by  means  of  a  curved  needle.  Bleeding  from 
the  pia  is  arrested  by  direct  ligation,  or  in  the  same  way  as  is 
bleeding  from  the  dura.  Bleeding  from  the  diploe  is  arrested 
by  the  use  of  Horsley's  wax.  The  wound  is  cleansed,  in 
some  cases  the  button  of  bone  is  re-introduced,  or  some 
chips  are  cut  from  the  bone  and  scattered  upon  the  dura. 
The  scalp  is  sutured  with  silkworm-gut  and  horse-hair  or 
gauze  drainage  is  employed  for  a  day  or  two.  Sterilized 
gauze  dressings  are  put  on,  a  rubber-dam  is  laid  over  them,, 
and  a  gauze  bandage  wet  with  bichlorid  of  mercury  is 
applied. 

Instead  of  the  trephine  some  surgeons  use  the  chisel  or 
gouge  and  hammer  to  remove  a  portion  of  the  bone.  Other 
operators  maintain  that  this  procedure  may  cause  concussion, 
and  employ  the  surgical  engine. 

Osteoplastic  Resection  of  the  Skull. — Wagner  devised 
the  osteoplastic  method  of  resection.  It  is  employed  for  the  re- 
moval of  tumors  and  the  Gasserian  ganglion,  and  for  explora- 
tion. A  horseshoe  incision  is  made  through  the  scalp  and 
periosteum,  a  groove  corresponding  to  this  incision  is  cut  in 
the  bone  by  special  gouges  or  chisels.  The  bone  is  chiselled 
through,  but  is  left  attached  to  the  scalp.  The  bone  is  then 
broken  outward,  the  fracture  taking  place  at  the  base  of  the 
bone-flap.  After  the  operation  the  bone  which  is  still  adhe- 
rent to  the  pericranium  is  restored  to  its  proper  place.  Some 
surgeons  use  the  surgical  engine  instead  of  the  chisel,  and 
others  make  trephine-openings  and  cut  from  within  outward 
by  means  of  the  Gigli  wire  saw  (Obalinski).  The  osteoplas- 
tic method  of  opening  the  skull  is  employed  when  a  large 
opening  is  necessary,  as  when  the  operation  is  first  of  all  for 
diagnosis.  Krause,  Keen,  and  others  employ  this  plan  in 
operating  to  remove  the  Gasserian   ganglion. 

Besides  restoring  a  flap  of  bone  into  position,  or  replacing 
a  button  of  bone,  or  strewing  the  dura  with  bone-fragments, 
other  methods  of  closing  the  opening  have  been  practised. 
For  instance,  heteropiasty  with  a  decalcified  bone-plate  and 
heteroplasty  with  a  celluloid  plate  or  other  foreign  material.* 

Trephining  the  Frontal  Sinus. — This  operation  may  be 
employed  for  inflammation  of  the  lining  membrane  of  the 
sinus  or  for  empyema.  Make  a  vertical  incision  in  the  middle 
of  the  forehead,  starting  one  and  one-half  inches  above  the 
nasion  and  terminating  at  the  root  of  the  nose.  The  button 
of  bone  is  removed  and  the  opening  is  enlarged  if  necessary. 

^  See  Bretano,  in  Deutsche  nied.  IVoch.,  May  17,  1S94. 


OPERATIOXS   OF   THE  SKULL   AXD   BRAIX.  689 

The  mucous  membrane  is  incised,  the  opening  into  the  nose 
is  found  and  is  dilated,  and  a  drainage-tube  is  passed  into  the 
nose  from  the  sinus,  the  upper  end  being  left  in  the  sinus. 
In  some  severe  cases  Jacobson  advises  us  to  curet  the 
sinus,  to  disinfect  it  by  the  use  of  silver  nitrate  or  chlorid  of 
zinc,  and  to  insufflate  an  "  aseptic  powder."  In  some  cases 
resect  the  mucous  membrane.  Some  surgeons  prefer  an 
osteoplastic  resection  to  trephining. 

Trephining  the  Mastoid  (page  690). 

Teclmique  of  Brain-operations  (after  Horsley  and  Keen). 
— Instruments  as  for  fractured  skull.  In  focal  epilepsy  a  fara- 
dic  batter}'  is  required.  Always  shave  the  scalp,  and  always 
antisepticize  it.  In  localizations,  mark  out  the  fissure  upon 
the  scalp  with  an  anilin  pencil  or  with  iodin.  Have  the 
patient  semi-recumbent.  ^lark  three  points  upon  the  bone 
with  the  center-pin  of  the  trephine  before  incising  the  scalp 
(both  ends  of  the  Rolandic  fissure  and  the  point  at  which 
the  trephine  will  be  applied).  ]\Iake  a  semilunar  flap  three 
inches  in  diameter,  with  the  base  below.  Control  bleeding  in 
the  flap  by  forceps  pressure.  The  one  and  a  half  inch  trephine 
should  be  employed,  but  if  a  smaller  trephine  is  used,  the 
opening  must  be  enlarged  with  a  rongeur.  Before  enlarging 
the  opening,  separate  the  dura  from  the  bone  by  a  dural 
separator.  As  a  rule,  open  the  dura  and  examine  the 
brain.  The  dura  is  lifted  by  rat-toothed  forceps  and  is 
opened  with  scissors  along  a  line  a  quarter  of  an  inch  from 
the  bone-edge,  a  broad  pedicle  of  dura  being  left  uncut. 
Hemorrhage  is  arrested  by  pressure  and  hot  water,  or  by 
passing  a  cun-ed  needle  threaded  with  catgut  around  any 
bleeding  vessel.  In  some  cases  packing  must  be  left  in  or 
forceps  must  be  kept  on.  In  packing,  endeavor  to  use  but 
one  piece  of  gauze,  so  as  to  avoid  lea^-ing  in  a  forgotten 
piece.  Upon  opening  the  dura  cerebrospinal  fluid  flows  out, 
the  stream  being  increased  with  each  expiration.  Absence 
of  pulsation  of  the  brain  points  to  tumor,  and  a  li\-id  color 
indicates  subcortical  gro^^'th.  An  old  laceration  is  brownish. 
If  the  brain  bulges  through  the  opening,  it  means  increased 
pressure  (tumor,  abscess,  effusion  into  the  ventricles,  etc.). 
After  opening  the  dura  employ  no  antiseptics,  especial!}-  when 
the  surgeon  intends  using  electricit}'  to  locate  a  center. 
Irrigate  onh'  with  warm  salt  solution.  In  operating  for  tumor 
the  dura  is  opened  and  in  some  cases  the  brain  is  incised. 
The  tumor  is  turned  out  by  the  finger,  or,  if  this  is  impossible, 
by  the  dr}-  dissector,  the  scissors,  the  dull  knife,  or  the  sharp 
spoon.  If  the  entire  tumor  cannot  be  removed,  take  awav  as 
44 


690  DISEASES  AND   INJURIES   OF  THE  HEAD. 

much  as  possible.  The  removal  of  a  portion  often  retards 
the  growth  of  the  remainder,  and  the  trephining,  by  les- 
sening cerebral  pressure,  relieves  the  symptoms  and  pro- 
longs life.  After  removing  a  tumor  arrest  distinct  points 
of  bleeding  with  the  ligature  alone  or  the  ligature  passed 
around  the  vessel  by  means  of  a  needle.  Pack  the  tumor- 
cavity  with  gauze  and  bring  the  end  of  the  plug  out  of 
the  wound.  Stitch  the  dura  with  silk  and  suture  the  scalp 
with  silkworm-gut.  In  electrifying  the  brain  faradism 
is  employed  of  a  strength  about  sufficient  to  move  the 
thenar  muscles  when  applied  to  them.  The  current  is  ap- 
plied to  the  motor  area  by  the  double  electrode.  A  careful 
observer  watches  the  muscular  movements.  If,  for  instance, 
the  surgeon  wishes  to  remove  the  thumb-center,  he  moves 
the  electrode  from  point  to  point  until  he  obtains  thumb- 
movements.  The  region  is  sliced  away  bit  by  bit  until  the  cen- 
ter which  is  responsible  for  the  convulsive  movements  is  re- 
moved. It  will  be  found  impossible  to  remove  only  the  thumb- 
center.  Adjacent  centers  are  sure  to  be  more  or  less  dam- 
aged, and  a  certain  amount  of  paralysis  follows  the  operation. 
If  we  wish  to  tap  the  ventricles,  Keen  directs  that  the  tre- 
phine-opening  be  one  and  one-fourth  inches  behind  the  exter- 
nal auditory  meatus  and  the  same  distance  above  the  base-line 
of  Reid  (Fig.  246,  a).  A  grooved  director  or  metal  tube  is 
passed  into  the  brain  in  the  direction  of  a  point  "  two  and 
one-half  to  three  inches  above  the  opposite  meatus."  The 
normal  ventricle  will  be  entered  at  a  depth  of  two  to  two 
and  one-fourth  inches,  but  the  dilated  ventricle  will  be  entered 
sooner  (Keen).  The  moment  of  entry  is  marked  by  lessened 
resistance  and  a  flow  of  cerebrospinal  fluid.  Drainage  can 
be  maintained  by  introducing  a  rubber  tube.  This  operation 
has  been  employed  in  hydrocephalus.  After  an  aseptic  cere- 
bral operation,  as  a  rule,  do  not  drain  unless  hemorrhage  has 
been  considerable.  In  many  cases  replace  the  bone,  but  not 
when  the  bone  is  diseased,  is  infected,  or  is  very  compact,  or 
if  it  is  desired  to  alter  pressure.  The  dura  is  sutured  by  a 
continuous  silk  suture  (Fig.  57);  the  scalp  is  sutured  by 
interrupted  silkworm-gut  sutures  (Fig.  56). 

Operation  for  Mastoid  Suppuration. — The  instruments 
required  in  this  operation  are  a  scalpel,  a  gouge,  a  chisel,  a 
mallet,  curets,  a  probe,  a  dissector,  dissecting-  and  hemo- 
static forceps,  and  needles.  Provide  a  sand-bag  to  place 
under  the  neck.  An  incision  is  made  one-quarter  of  an  inch 
posterior  to  the  auricle  and  down  to  the  bone,  and  in  the 
direction  of  the  long  axis  of  the  mastoid.     The  bone  is  bared 


OPERATIOXS   OX  THE   SKULL   AXD   BRAIN. 


691 


and  examined,  especially  at  a  point  in  the  line  of  the  incision 
which  is  on  a  level  with  the  roof  of  the  meatus  (Fig.  246,  c). 
The  bone  will  usually  be  found  softened.  Gouge  it  away 
and  thus  open  the  mastoid  antrum.  This  bone-opening  is 
within  the  limits  of  Macewen's  suprameatal  triangle,  a  space 
bounded  by  the  posterior  root  of  the  zygoma,  the  posterior 
bony  wall  of  the  meatus,  and  an  imaginary  line  joining  the  two. 


Fig.  246. — Opening  the  mastoid  antrum  and  the  lateral  sinus;  exposure  of  the  teraporo- 
sphenoidal  lobe  and  puncture  of  the  descending-  horn  of  the  lateral  ventricle  :  a,  temporo- 
sphenoidal  lobe  (descending  cornu  of  lateral  ventricle  is  i  cm.  deeper)  ;  b,  inner  surface  of 
periosteum:  <:,  mastoid  antrum  ;   ^,  lateral  sinus  (Kocher). 

If  the  mastoid  is  opened  in  this  triangle,  the  antrum  is  entered 
directly  and  there  is  no  chance  of  wounding  the  lateral 
sinus.  If,  in  the  adult,  pus  is  not  found  on  opening  the  mas- 
toid antrum,  gouge  downward  and  backward,  but  with  great 
care,  so  as  to  avoid  the  lateral  sinus.  If  there  be  any  possi- 
bility of  the  existence  o'f  pus  in  the  groove  of  the  sinus,  the 
sinus  should  be  unhesitatingly  exposed.  After  evacuating 
the  pus  scrape  the  cavities  with  the  curet,  enlarge  the 
opening  between  the  mastoid  and  the  middle  ear  with  the 


692  DISEASES  AND   INJURIES    OF   THE   HEAD. 

gouge,  turn  the  head  toward  the  side  operated  upon,  and 
irrigate  the  mastoid  with  corrosive-sublimate  solution 
(i  :  2000) ;  dust  in  iodoform,  pack  with  iodoform  gauze  for  a 
few  days,  and  then  introduce  a  silver  drainage-tube.  Treat 
the  causative  ear  disease.  A.  Marmaduke  Sheild  and 
Macewen  operate  on  inveterate  cases  of  mastoid  disease  as 
follows  :  a  thick  flap  is  raised  behind  the  auricle,  the  flap 
including  the  orifice  of  any  sinus  and  being  "  left  attached  by 
its  stalk."  The  auricle  is  "  detached  forward  and  the  soft  parts 
over  the  mastoid  are  turned  backward  by  horizontal  in- 
cision." The  "  lining  membrane  of  the  canal  is  separated 
from  the  bone."  The  mastoid  is  opened  and  dead  bone 
and  caseous  matter  are  removed,  overhanging  edges  are 
chiselled  down,  and  the  posterior  bony  wall  is  gouged  away. 
The  skin-flap  is  pushed  into  the  cavity  and  is  held  in  place 
with  pads  of  gauze.  The  margins  of  the  flap  may  be  sutured, 
but  this  is  not  necessary.  Macewen  calls  this  procedure 
"papering"  the  cavity  with  skin.^ 

If  mastoid  suppuration  has  established  abscess  in  ilie 
tcmporosplienoidal  lobe,  trephine  one  and  a  quarter  inches 
behind  and  one  and  a  quarter  inches  above  the  middle  of 
the  external  meatus  (Barker's  point.  Fig.  246,  ci)  and  search 
for  pus  as  directed  on  page  (i'j'j.  If  abscess  of  the  cerebellum 
exists,  trephine  below  the  line  of  the  lateral  sinus.  "  The 
position  of  the  lateral  sinus  is  indicated  by  a  line  running 
horizontally  outward  from  the  occipital  protuberance  to 
within  about  an  inch  of  the  external  auditory  meatus,  and 
thence  downward  to  the  mastoid  process  "  (Owen's  Maiiual 
of  Anatomy).  If  mfectme  smus-th'ombosis  exists,  break  into 
the  lateral  sinus  (Fig.  246,  d)  through  the  mastoid  opening 
and  proceed  as  directed  on  page  679. 

Linear  Craniotomy. — Instruments  as  for  any  brain  opera- 
tion, plus,  however,  several  kinds  of  rongeur  forceps.  Make 
a  large  flap.  Trephine  the  skull  a  finger's  breadth  from  the 
sagittal  suture,  and  the  same  distance  back  of  the  coronal 
suture.  Rongeur  the  bone  away  in  a  line  parallel  with  the 
sagittal  suture  up  to  a  point  in  front  of  the  lambdoidal 
suture.  Remove  the  pericranium  which  covered  the  bone 
excised.  Insert  the  dural  separator,  or  pass  it  along  the 
margins.  In  some  cases  an  additional  portion  of  the  bone 
is  removed  over  the  fissure  of  Rolando.  Various  sugges- 
tions have  been  made  as  to  the  direction  and  situation  of 
bone-sections.  Bleeding  is  arrested  and  the  flap  is  closed 
without  drainage. 

1  Laticet,  Feb.  8,  1896. 


COXGEXITAL   DEFORMITIES.  693 

Removal  of  Gasserian  Ganglion  (page  648). 
Operation  for  Infective  Sinus-thrombosis  (page  679). 

XXIV.  SURGERY  OF  THE  SPINE. 

Congenital  Deformities. — Spina  bifida,  or  hydrorrha- 
chitis,  is  a  congenital  cystic  tumor  due  to  vertebral  deficiency, 
permitting  protrusion  of  the  contents  of  the  spinal  canal  in 
the  median  line.     The  laminae  or  spines  of  one  vertebra  or 
of  several  vertebrae  may  be  deficient,  most  frequently  in  the 
lumbosacral  region.      Manngocde  is  a  protrusion  of   dura 
mater  and  arachnoid,  the  sac  containing  cerebrospinal  fluid, 
but   no   nerves    and   no  cord-substance.      Meningomyelocele 
(the  commonest  form)  is  a  protrusion   of   dura  mater  and 
arachnoid,  the    sac    containing    cerebrospinal    fluid,   nerves, 
and  cord-substance.     The  cord  may  spread  upon  the  sac- 
wall  or  it  may  pass  through  the  sac  and  re-enter  the  canal. 
Syringomyelocele   is    great    distention    of  the  central  canal, 
the  sac-wall  being  formed  of  the  thinned  cord.      A  spina 
bifida  varies  in  size  from  that  of  a    walnut    to  that  of  an 
infant's  head;  it  grows  rapidly  during  the  early  weeks  of 
life;  it  is  usually  sessile,  but  may  present  where  it  joins  the 
body  a  definite' constriction,  or  even  a  pedicle;  the  base  of 
the  'sac   is   covered    with    healthy  skin,  and    the    fundus   is 
covered  only  by  thin  epidermis  or  by  the  spinal  membranes 
themselves.     Pressure  upon  the  tumor  is  found  to  diminish 
its  size  and  to  increase  the  tension   of  the  anterior  fontanel, 
and  possibly  to  cause  convulsions   or  stupor.     The  cyst  is 
transculent,'and  the  margins  of  the  bony  aperture  are  dis- 
tinct.      Crying,   coughing,  or    pressure    upon    the    anterior 
fontanel  makes  the  tumor  more  tense.     Spina  bifida  is  apt 
to   be    associated    with    club-foot,  with    hydrocephalus,  and 
with  rectal  or  vesical  paralysis,     Spina  bifida  usually  causes 
death.     A  few  meningocel'es  and  a  very  few  meningomyelo- 
celes undergo  spontaneous  cure  by  the  shrinking  of  the  sac. 
Syringomyelocele  is  invariably  fatal.     The  cause  of  death 
may  be  rupture  of  the  sac  or  marasmus. 

Treatment. — Very  small  protrusions  which  grow  slowly 
and  are  covered  with  sound  skin  may  be  treated  by  the  use 
of  a  compress  and  bandage,  by  an  elastic  bandage,  or  by 
applications  of  contractile  collodion.  It  was  formerly  re- 
garded as  proper  to  tap  and  drain  the  sac.  Injection  was 
used  by  many.  The  sac  being  cleaned,  the  child  was  placed 
on  its  side  and  a  little  chloroform  was  given.  A  fine  trocar 
was  plunged  obliquely  in  at  the  side  through  sound  skin, 


694  SUJ^GEIiY  OF   THE  SPINE. 

little  or  no  fluid  being  drawn  off,  and  3j  of  Morton's  fluid 
injected  (iodin,  gr.  x ;  iodid  of  potassium,  gr.  xxx ;  gly- 
cerin, 5J).  The  trocar  was  withdrawn  and  the  puncture  was 
sealed  with  a  bit  of  gauze  and  iodoform  collodion.  The 
child  was  put  to  bed.  If  injection  proved  successful,  the  sac 
was  found  to  shrink ;  if  the  injection  failed,  it  was  the  custom 
to  repeat  it  at  intervals  of  from  seven  to  ten  days  (Jacobson, 
White).  Surgeons  now  prefer  excision  of  the  sac.  Bayer 
treats  it  as  he  would  a  hernia.  Robson  in  some  cases  excises 
the  entire  sac. 

Tumors  of  the  Spine. — Among  congenital  tumors  are 
lipomata  -and  cysts  (dermoid,  congenital,  sacral,  and  fetal). 
Tubercle,  gumma,  psammoma,  and  fibroma  may  arise  from 
the  cord  or  its  membranes.  Glioma  is  the  most  usual 
growth.  Primary  sarcoma  is  rare.  Angeioma  may  occur. 
Primary  carcinoma  does  not  occur  in  this  region.  A  tumor 
rarely  produces  obvious  symptoms  until  it  is  as  large  as  a 
hazel-nut. 

Symptoms  and  Treatment. — Pain,  stiffness  of  the  back, 
areas  of  anesthesia,  and  progressively  advancing  motor 
paralysis  are  symptoms  of  spinal  tumors.  A  tumor  may 
produce  the  symptoms  of  compression-myelitis,  locomotor 
ataxia,  or  myelitis.  In  glioma  there  are  apt  to  be  loss  of 
ability  to  recognize  variations  of  temperature  (or  even  to 
distinguish  between  heat  and  cold),  loss  of  the  sense  of  pain, 
and  paresis  and  atrophy  of  muscles.  Contractures  or  para- 
plegia may  arise.  The  location  of  the  tumor  can  be  inferred 
by  a  study  of  the  territory  of  paralysis  and  the  zone  of  sen- 
sory disturbance.  The  tumor  is  always  situated  somewhat 
above  the  upper  limit  of  anesthesia.  In  many  cases  the  diag- 
nosis is  impossible.  Gradually  increasing  painful  paraplegia 
with  pain  in  the  back,  or  with  sensory  paralysis  after  a  time 
appearing  and  ascending  from  the  feet  toward  the  trunk, 
points  to  tumor  as  a  cause.  The  reflexes  are  at  first  increased, 
but  are  finally  lost  from  below  upward.  Spasms  may  develop, 
and  lateral  spinal  curvature  may  arise.  If  curvature  arises, 
the  concavity  of  the  curve  will  be  on  the  side  of  the  tumor. 
Growths  outside  the  membranes  produce  particularly  pain 
and  spasm ;  growths  within  the  membranes  produce  espe- 
cially motor  paralysis  and  anesthesia.  If  syphilis  is  sus- 
pected, give  the  patient  a  course  of  heroic  doses  of  iodid  of 
potassium,  and  administer  mercury  hypodermatically.  In  a 
focal  lesion  not  due  to  dissemination  of  a  known  malignant 
growth  perform  the  operation  of  laminectomy  to  permit  of 
exploration  and  possibly  of  removal. 


SPINAL    CURVATURES.  695 

Acute  osteomyelitis  of  the  vertebrae  is  a  rare  dis- 
ease ;  it  may  be  associated  with  osteomyelitis  of  other  bones, 
but  may  occur  alone.  Infections  of  the  viscera  not  unusu- 
ally accompany  it.  Any  part  of  a  vertebra  may  suffer  from 
it.  This  condition  arises  from  cold,  over-exertion,  or  trau- 
matism, and  is  more  common  in  the  young  than  in  the  old. 
The  process  may  be  superficial,  or  it  may  involve  the  bone 
deeply  and  widely.  Suppuration  always  occurs;  sequestra 
generally  form ;  and  phlebitis  is  a  dangerous  complication. 
Any  region  of  the  spine  may  be  attacked,  but  the  lumbar 
region  is  particularly  liable  to  invasion.  The  situation  of  the 
abscess  varies  with  the  situation  of  the  disease.  If  the  verte- 
bral bodies  are  diseased,  the  pus  passes  forward  (retrophar- 
yngeal, mediastinal,  psoas,  or  pelvic  abscess).  If  the  verte- 
bral arches  suffer,  the  pus  passes  backward  (lumbar  or  dorsal 
abscess).  The  membranes  of  the  cord,  the  cord  itself,  the 
nerves,  and  the  vertebral  articulations  are  frequently  involved 
in  the  process.  Staphylococci  or  streptococci  may  be  grown 
from  the  pus. 

Symptoms. — The  general  symptoms  are  those  of  osteo- 
myelitis. The  local  symptoms  depend  on  the  seat  of  disease. 
If  the  posterior  portion  of  the  column  is  diseased,  there  is 
a  hard  swelling,  which,  in  the  neck,  is  in  the  m.iddle  line ; 
in  the  dorsal  and  lumbar  regions,  in  the  middle  or  to  the 
side ;  and  in  the  sacral  region,  invariably  to  one  side. 

Rigidity  always  exists.  If  the  vertebral  bodies  are  affected, 
rigidity  is  noted,  the  spine  is  tender,  and  special  symptoms 
arise  dependent  on  the  region  affected  (retropharyngeal 
abscess,  etc.).  Occasionally  symptoms  of  meningomyelitis 
are  noted.  The  constitutional  symptoms  of  sepsis  are  marked. 
The  condition  is  sudden  in  onset,  and  purulent  collections 
diffuse  widely  and  rapidly.  These  points  enable  the  surgeon 
to  make  a  diagnosis  between  osteomyelitis  and  Pott's  dis- 
ease. In  osteomyelitis  angular  deformity  very  rarely  arises, 
because  the  patient  is  obliged  to  be  recumbent  and  because 
hyperostosis  is  taking  place. 

'Treatment. — The  patient  is  kept  recumbent.  His  consti- 
tutional treatment  is  such  as  will  combat  sepsis  (food,  stimu- 
lants, etc.).  A  puriform  area  must  be  incised  and  disinfected. 
If  bone  denuded  of  periosteum  is  found,  it  is  touched  with 
a  solution  of  chlorid  of  zinc  or  with  the  actual  cautery.  If  a 
sequestrum  exists,  it  is  removed.  A  drainage-tube  is  inserted 
and  dressings  are  applied  (Miiller,  Makins,  Abbot,  and  Chi- 
pault). 

Spinal    Curvatures. — There   are   four   chief  forms    of 


696  SURGERY  OF  THE   SFIA^E. 

Spinal  curvature:  (i)  lateral  curvature  (the  scoliosis  of  the 
older  surgeons);  (2)  posterior  curvature  (the  excurvation, 
gibbosity,  or  kyphosis  of  the  older  surgeons) ;  (3)  anterior 
curvature  (the  lordosis  of  the  older  surgeons) ;  and  (4)  angu- 
lar curvature  (from  spinal  caries).  The  normal  spine  has 
four  curves  :  the  cervical  curve,  the  convexity  of  which  is 
forward ;  the  dorsal  curve,  the  convexity  of  which  is  back- 
ward; the  hiDibar  curve,  which  is  convex  anteriorly;  and 
the  pelvic  curve,  which  is  concave  anteriorly.  The  dorsal 
and  the  pelvic  curves,  which  are  primary,  are  due  to  the 
formation  of  the  cavities  of  the  chest  and  pelvis,  and  depend 
upon  the  shape  of  the  bones  (Treves).  The  cervical  and 
lumbar  curves,  which  are  compensatory,  depend  upon  the 
shape  of  the  intervertebral  disks,  and  only  appear  after  birth 
when  the  erect  position  is  assumed. 

Lateral  curvature  (scoliosis)  is  a  lateral  deviation  of  the 
spinal  column,  often  accompanied  with  rotation  of  the  ver- 
tebrae and  associated  with  increase  or  with  diminution  of  the 
normal  curves.  Lateral  curvature  is  predisposed  to  by  weak 
muscles  and  ligaments,  by  the  habitual  assumption  of  strained 
and  unnatural  attitudes,  by  unequal  length  of  the  legs,  and 
by  paralysis  of  one  leg.  This  distortion,  which  is  commonest 
in  girls,  is  apt  to  arise  at  the  age  of  puberty  (it  is  usually 
corrected  in  boys  by  outdoor  exercise).  The  bones  are  soft 
and  the  muscles  are  weak,  and  this  condition  is  often  inher- 
ited. Rickets  is  very  commonly  associated  with  lateral  curva- 
ture. Any  condition  of  ill-health  weakens  the  muscles;  hence 
lateral  curvature  may  arise  after  an  acute  sickness  or  in  a 
person  who  outgrows  his  strength.  An  em- 
pyema with  adhesions,  by  pulling  on  the  chest- 
wall,  may  produce  a  curvature  the  concavity  of 
which  is  toward  the  diseased  side. 

The  weak  muscles  cease  to  sustain  the  spi- 
nal column,  and  the  ligaments   stretch,  relax, 
or  lengthen.     The  commonest  curve  is  toward 
the  right  in   the   dorsal  region  (because  most 
people  use  the  right  hand  more  than  the  left). 
As  soon  as  a  dorsal  curve  to  the   right  arises 
a  compensatory  lumbar  curve  (Fig.  247)  takes 
Fig.    247.  —     place  to  the  left,  thus  enabling  the  patient  still 
^urvltire  w?he     to  sit   or  to   staud  crcct.     In  almost  all  cases 
right  and  com-     ^j^g  vertebrae  soon   rotate,  the  bodies  turning  to 

pensatory     mm-  .  '     _  _  o 

bar  curve  to  the     the   couv^exity   and  the  spines   turning  to   the 

concavity  of  the  curve ;  hence  the  transv^erse 

processes  toward  the  convexity  project.     The  ribs  follow  the 


SPINAL    CURVATURES.  697 

spinal  rotation ;  the  shoulder  is  elevated  on  the  side  of  the 
convexity,  and  the  hip  on  the  same  side  is  raised.  The 
intervertebral  disks  are  apt  to  flatten  out  on  the  concavity 
of  the  curve.  In  very  rare  instances  lateral  curvature 
results  from  caries  of  a  half  of  one  or  of  several  vertebrae. 
In  a  spinal  tumor  lateral  curvature  may  occur,  the  concavity 
of  the  bend  being  on  the  side  of  the  growth. 

Symptoms.— An   ordinary   case   of  spinal   curvature  from 
weak   muscles   arises   gradually.     Stooping  is   noticed,  and 
after  a  time  pain  is  complained  of  in  the  dorsal  and  lumbar 
regions,  and  weakness  in  the  back  is   detected  by  the  suf- 
ferer.    The  pain  is  made  more  severe  by  sitting  long  m  one 
attitude.     Anemia  is  manifest,  and  walking  is  awkward  and 
ungraceful.     When  the  shoes  and  clothing  are  removed,  and 
the'  child  stands  with  its  back  toward  the  surgeon  and  with 
the  feet  symmetrically  together,  the  lower  angle  of  the  right 
scapula  (in  a  dorsal  curvature  to  the  right)  is  unduly  promi- 
nent and  is  elevated  above  the  left ;  the  normal  prominence 
of  the  left  iliac  crest  is  lost ;  the  right  iliac  crest  is   unduly 
distinct ;  on   marking  the  spinous  processes  with   an   anilin 
pencil  the  curve  becomes  manifest ;  tenderness  is  often  devel- 
oped on  pressing  the  spines  ;  the  normal   dorsal  anteropos- 
terior curve  is  exaggerated;  the  abdomen  is  protuberant; 
the  chest  is  flattened;  the  neck  juts  forward;  and  the  breast 
on    the    same    side    as  the  concavity  of  the  curve  is  more 
prominent    and    on    a    lower    level    than    the  other   breast. 
Always  observe  if  the  anterior  iliac  spines  are  on  a  level  or 
not,  and  always  measure  the  length  of  the  legs.  The  patient, 
with  the  knees  extended,  bends  forward  with  the  arms  hang- 
ing loosely :  the  erector  spinae  muscle  between  the  iliac  crest 
aiid  the  last  rib  is  seen  to  be  more  prominent  on   the  con- 
vexity of  the  lumbar  curve  than  on  its  concavity  (Bernard 
Roth),  and  the  angles  of  the   ribs   on   the  side  of  the  con- 
vexity of  the  dorsal  curve  are  on  a  higher  level  than  are 
those  on  its  concavity.     Have  the  child  assume  what  it  sup- 
poses to  be  an  erect  attitude,  and  let  the  surgeon  correct  this 
into  the  best  possible  position  (Roth),  and  see  how  long  the 
new  position  can  voluntarily  be   maintained.     A  large  per- 
centage of  these  patients   labor  under  pes   planus.     When 
there    is    no  osseous  deformity  (that  is,  when  the  surgeon 
may,  by  manipulation  and  traction,  correct  the  deformity), 
and  when  the  spinal  muscles  are  not  paralyzed  the  prognosis 
is  good  for  complete  cure.     Roth  states  that  cases  without 
os?eous   deformity  can  practically  be  cured  in  one  month, 
but  the  treatment  must  be  continued  for  one  year  to  prevent 


698  SUJiGERY  OF   THE   SPINE. 

relapse.^  In  a  case  with  moderate  osseous  deformity  the 
patient  can  be  improved  vastly  by  three  months'  daily 
treatment  (Roth).  Even  in  severe  cases  of  bony  deformity 
the  pain  may  be  relieved  and  the  deformity  be  modified. 

Treatment. — If  one  leg  is  too  short,  let  the  patient  wear  a 
thick-soled^  shoe.  No  treatment  for  weak  muscles  has  ever 
been  devised  so  utterly  irrational  and  absurd  as  the  preven- 
tion of  all  movement ;  and  neglect  of  all  treatment  for  lateral 
curvature  does  less  harm  in  the  vast  majority  of  cases  than 
immobilizing  the  spinal  muscles  by  braces  and  supports. 
The  muscular  nutrition  in  these  cases  is  to  be  restored, 
as  is  muscular  nutrition  in  any  other  region,  by  scientific 
gymnastics,  electricity,  the  douche,  salt  baths,  frictions,  and 
massage.  Bicycles  with  specially  constructed  seats  are 
used  with  advantage  in  some  cases.  The  mode  of  exer- 
cise to  be  used  should  be  directed  by  some  one  skilled 
in  orthopedics,  and  the  instruction  in  the  details  must  be 
thorough  and  persistent.  Roth's  advice  is  to  so  re-educate 
the  muscular  sense  that  a  patient  can  again  know  whether 
she  is  or  is  not  standing  straight;  to  maintain  an  im- 
proved position  in  sitting  and  standing ;  to  use  such  cloth- 
ing as  will  not  interfere  with  the  assumption  of  a  normal 
attitude ;  to  enforce  systematic  training  of  the  muscles  of 
the  spine  and  thorax;  and  to  give  attention  to  the  general 
health.  In  some  cases  where,  in  spite  of  all  attempts  at 
correction,  deformity  increases,  it  may  be  necessary  to  immo- 
bilize in  hope  of  obtaining  ankylosis  and  preventing  further 
deformity.  In  those  rare  lateral  curvatures  due  to  caries  a 
supporting  apparatus  must,  of  course,  be  applied. 

Anteroposterior  ciirvature  (not  from 
spinal  caries   or  from  hip-point  disease) 
is    an    increase    of    the    normal    antero- 
posterior curves.      Increase  of  the  dor- 
sal curve  is  posterior  curvature,  kyphosis, 
or  excurvation  (Fig.  248,  a)  ;  increase  of 
the  lumbar  curve  is  anterior  curvature, 
lordosis,   or    saddle-back  (Fig.    248,   b). 
Both  lordosis  and  kyphosis  are  apt    to 
be  present.     Scoliosis  has  nearly  always 
some    anteroposterior    curvature    asso- 
'^'andl^rdorb"?).^"^'        clatcd   with   it.     Lordosis    is    apt   to   be 
compensatory,  to  prevent  the  center  of 
gravity  going  too  far  forward.     Lordosis  is  found  in  pregnant 
women  and  in  very  fat  men.     In  an  old  man  kyphosis  arises 

^  Heath's  Dictionary  of  Practical  Sttrgery. 


SPINAL    CURVATURES.  699 

from  flattening  out  of  the  vertebral  disks  from  pressure. 
Rheumatic  gout  may  cause  anteroposterior  curvature.  An- 
teroposterior curvature  is  often  due  to  paralysis  of  the  erector 
spinse  mass  (from  infantile  paralysis.)  Pseudohypertrophic 
paralysis  causes  lordosis. 

Syinptoms  and  TreatDicnt. — The  symptoms  of  anteropos- 
terior curvature  are  as  follows  :  the  thorax  is  flattened  or 
pigeon-breasted ;  the  shoulder-blades  are  widely  separated 
and  the  scapular  angles  project ;  the  abdomen  is  protuberant ; 
the  patient  complains  of  backache  and  soon  tires.  A  recent 
kyphosis  disappears  when  the  patient  lies  upon  his  stomach. 
The  facts  that  the  erector  spinae  muscles  are  soft,  and  that 
pain  is  absent  on  concussion  transmitted  from  the  heels, 
separate  kyphosis  from  caries.  Lordosis  is  unmistakable. 
When  the  spine  is  movable  employ  the  same  plan  of  treat- 
ment as  that  in  lateral  curvature,  suiting  the  gymnastics 
to  the  deformity  (Roth).  In  painful  kyphosis  with  partial 
ankylosis  endeavor  to  make  the  ankylosis  complete  in  order 
to  prevent  pain,  obtaining  this  result  by  applying  a  plaster 
jacket  which  laces  up  and  letting  the  patient  wear  it  for 
several  years. 

Ang-ular  curvature  (Spinal  Caries ;  Spondylitis ;  Pott's 
Disease)  is  usually  due  to  tubercular  caries  of  the  vertebral 
bodies,  and  occurs  particularly  in  children  who  are  predis- 
posed to  tuberculosis,  but  it  may  arise  at  any  age.  Any  por- 
tion of  the  spinal  column  may  be  attacked.  The  dorso- 
lumbar  region  is  most  prone  to  suffer.  The  chief  cause 
is  tuberculosis,  but  syphilis,  secondary  cancer,  and  acute 
myelitis  of  the  vertebrae  are  occasional  causes.  Blows  or 
strains  are  often  exciting  causes.  Angular  curvature  may 
develop  after  an  exanthematous  fever. 

The  cancellous  tissue  of  the  anterior  portion  of  a  verte- 
bral body  becomes  primarily  carious,  or  the  inflamma- 
tion begins  in  an  intervertebral  disk.  (The  changes  of 
tubercular  osteitis  have  previously  been  set  forth.)  The 
body  of  the  vertebra  and  the  vertebral  disk  are  destroyed, 
and  the  process  extends  to  adjacent  vertebrae.  The  weight 
which  rests  upon  the  spinal  column  causes  softened  bone 
to  crumble,  compresses  the  diseased  vertebrae  and  disks, 
and  produces  angular  deformity  (the  anterior  part  of  the 
spine  formed  by  the  vertebral  bodies  is  shortened,  the  pos- 
terior part  is  not,  and  hence  the  spines  project).  In  some 
cases  the  disease  is  spontaneously  arrested  by  organization 
of  inflammatory  products,  and  ankylosis  (fibrous  or  bony)  in 
deformity  is  Nature's  cure.     In  most  cases,  however,  the  dis- 


700 


SURGERY  OF  THE   SPINE. 


ease  spreads  and  caseous  pus  is  formed,  which,  according  to 
the  route  it  takes,  causes  lumbar  abscess,  dorsal  abscess, 
psoas  abscess,  or  postpharyngeal  abscess  (page  136).  In 
some  cases  the  spinal  cord  is  compressed,  but  m  most 
cases  it  is  not,  and  even  when  it  is  compressed  paraplegia 
is  rare  and  is  usually  temporary.  Compression  of  the 
cord  may  be  caused  by  the  displaced  vertebrae  or  by  in- 
flammatory material  or  caseous  matter  between  the  bone 
and  dura  mater,  but  is  most  often  due  to  pachymeningitis. 
Caries  of  the  cervical  region  constitutes  a  more  danger- 
ous disease  than  caries  of  either  the  dorsal  or  the  lumbar 
region  (dangerous  pressure  occurs  more  easily).  Death 
may  be  caused  by  exhaustion,  sepsis,  hemorrhage,  amyloid 
disease,  pneumonia,  peritonitis,  pleuritis,  tubercular  dissemi- 
nation, pressure  upon  the  cord,  or  inflammation  of  the  cord 
or  its  membranes. 

Symptoms. — The  first  symptom  of  angular  curvature  is 
pain  in  the  back,  which  is  increased  by  motion,  by  pressure, 
and  by  vertebral  jars.  Neuralgic  pains  pass  into  distant 
parts  (sciatica,  intercostal  neuralgia)  and  are  often  Hnked 
with  muscular  spasm.  Pain  may  not  appear  until  late  in  the 
progress  of  the  case.  A  chronic  bilateral  pain  in  the  trunk 
or  extremities  is  suggestive  of  Pott's  disease.  "  Chronic  bilat- 
eral belly-aches  in  children  are  almost  diagnostic  "  (Jordan 
Lloyd).  The  pain  of  dorsal  caries  can  be  relieved  by  lifting 
the  shoulders ;  the  pain  of  cervical  caries  by  traction  on  the 
head.  Cramp  in  the  legs  occurs  in  dorsal  and  in  lumbar  caries. 
The  sufferer  from  Pott's  disease,  if  a  child,  grows  tired  easily, 
his  disposition  alters,  he  becomes  moody  and  irritable,  and 
complains  of  vague  pains  in  many  places,  is  disposed  to  lean, 
rest,  or  lie  down,  and  walks  with  the  back  rigid,  which 
produces  a  peculiar  gait.  A  painful  spot  is  found  by  press- 
ing upon  the  spines,  and  the  same  spot  is  painful  on  pressing 
the  head  downward  or  upon  jarring  the  entire  spine.  Fara- 
dism  to  the  back  causes  pain.  Spasm  of  the  erector  spinae 
mass  is  detected  (Hilton,  Golding-Bird).  The  presence 
of  the  knuckle  due  to  bending  the  spine  at  an  acute  angle 
is  a  very  important  sign  of  the  disease.  In  many  cases 
angular  deformity  appears  late,  in  some  cases  it  does  not 
appear  at  all.  An  angular  deformity  is  detected  sooner  in 
those  regions  where  the  normal  curves  are  posterior  than 
where  normal  curves  are  anterior  (Jordan  Lloyd).  The 
deformity  appears  early  in  the  dorsal  region,  but  late  in  the 
cervical  and  lumbar  regions.  In  some  rare  cases  lateral 
deformity  occurs.     Rigidity  is  an  early  sign  of  great  impor- 


SPIXAL    CURVATURES.  10\ 

tance.     It  is  always  present.     Rigidity  is  manifest  veiy  early 
in  cervical  caries,  tolerably  early  in  lumbar  caries,  late  in  dorsal 
caries.     Lloyd  gives  the  following  practical  rules  to  enable  us 
to  detect  rigidity.^    In  the  cervical  region  :  seat  the  patient  in  a 
chair  and  tell  him  to  nod  the  head  affirmatively.    Stiffness  in 
nodding  points  to  occipito-atloid  disease.     Tell  him  to  look 
far  to  the  right  and  then  far  to  the  left.     Stiffness  of  these 
motions  suggests  atlo-axoid  disease.     Tell  him  to  place  his 
shoulders  against  the  back  of  the  chair  and  carry  his  eyes 
back  along  the  ceiling.     Stiffness  in  this  movement  indicates 
disease  betow  the  second  cervical  vertebra.     It  is  practically 
useless  to  examine  the  dorsal  region  of  an  adult  for  rigidity, 
but  such  an  examination  can  be  made  in  a  child.     Place  the 
patient  prone  on  an  adult's  lap,  mark  the  tip  of  each  spinous 
process  with  an  anihn  pencil,  make  the  child  stand  up  straight, 
and  obser\-e  if  any  of  the  marks  fail  to  come  nearer  together, 
If  it  is  seen  that  two  or  more  marks   do  not  approach  each 
other,  there  is  rigidity  which  prevents   approximation.     To 
test  for  rigidit>^  in  the  lumbar  region   lay  the  naked  patient 
prone  upon  a  couch.     Grasp  the  patient's  ankles  and  raise 
the  pelvis  from  the  couch.     If  the  lumbar  spine  is  flexible, 
the  pelvis  can  be  lifted  without  raising  the  chest  from  the 
bed,  and  the  maneuver  deepens  the  hollow  of  the  loin.     If 
the 'lumbar  spine  is  stiff,  the  maneuver  lifts  the  trunk  and 
produces    no    alteration    in    vertical   outline   of   the   lumbar 
spines.     If  a  child  with  Pott's  disease  is  asked  to  pick  up 
something  from  the  ground,  because  of  rigidity  or  pain  on 
movement  he  will    not   bend   the   back,  but  wall  bend  the 
knees  or  get  upon  the  knees.     Paralysis  may  exist,  and  it 
is  due  to  pachymeningitis  more  often  than  to  pressure  from 
bone.     Cervical  caries  causes    dyspnea    and    torticollis,  the 
head  requiring  support  with  the  hands.     Dysphagia  indicates 
abscess.     In  adults  the  first  signs  of  Pott's  disease  to  attract 
attention     are     headache,   backache,   neuralgia,    girdle-pain, 
cramp,  or  even  paralysis.     In  abscess  due  to  caries  of  the 
dorsolumbar   vertebrae    the    pus    usually    enters    the    psoas 
muscle  and  passes  out  of  the  pelvis  below  the  junction  of 
the  middle  and  outer  thirds  of  Poupart's  ligament.     It  may 
point  here  or  mav  pass  to  the  inner  aspect  of  the  thigh  and 
point  a  little  below  the  spot  where  a  femoral  hernia  is  met 
with  if  it  exists.     In  sacral  caries  there  is  no  deformity-  and 
frequently  no  pain.     The  diagnosis  becomes  apparent  when 
bilateral  abscess  is  detected  in  the  buttocks  or  groins  (Jordan 
Lloyd).     If  an  abscess  due  to  spinal  caries   opens  sponta- 

1  Birmingham  Med.  Review,  April,  1897. 


702 


SURGERY  OF   THE   SPINE. 


neously,  healing  will   not   occur,  but   mixed  infection  takes 
place  and  death,  as  a  rule,  soon  follows. 

Treatment  of  Caries  of  the  Spine. — When  recent  caries  of 
the  spine  is  active  and  affects  a  child,  when  it  is  accompa- 
nied with  pain  and  fever,  and  when  paralysis  threatens,  insist 
upon  perfect  rest.  Place  the  child  supine  on  a  hard  mattress, 
and,  if  possible,  take  it,  while  in  a  rolling  bed,  out  of  doors 
daily.  Leeches,  blisters,  or  the  hot  iron  over  the  area  of  pain 
may  do  good.  When  the  activity  of  the  process  abates  apply 
a  fixation  apparatus.  In  diseases  at  or  near  the  vertebro- 
occipital  articulation,  as  long  as  dyspnea  persists,  keep  the 
patient  supine  with  a  small  hard  pillow  under  the  nape  of 
the  neck  (Hilton)   and  a  sand-bag  on  each  side  of  the  head 


Fig.  249. — Plaster-of-Paris  jacket  (Sayre). 


Fig.  250. — Plaster-of-Paris  jacket  and 
jury-mast  applied  (Sayre). 


and  neck.  After  several  months  mechanical  support  can  be 
given  by  Furneaux  Jordan's  method.  Jordan  applies  his 
support  as  follows  :  the  patient  lies  on  a  flat  hard  table,  his 
arms  are  raised  above  his  head,  and  traction  is  made  upon 
the  head  by  means  of  a  pulley  and  a  weight.  Cotton  pads 
are  placed  over  the  ears,  the  back  of  the  neck,  and  the  clav- 
icles, and  are  held  in  place  by  a  flannel  bandage  applied 
as  a  figure-of-8  of  the  head,  neck,  and  chest.  The  flannel 
bandage  is  overlaid  with  plaster-of-Paris  bandages.^  In 
disease  of  the  cervical  region  below  the  axis  use  Sayre's 
jury-mast  (Fig.  250).  This  appliance  relieves  the  spine  from 
the  weight  of  the  head  and  acts  admirably.     In  most  cases 

^  See  Children's  Deformities,  by  Walter  Pye. 


SPIXAL    CURVATURES.  703 

of  dorsal  and  lumbar  caries  some  fixation  apparatus  must 
be  employed.  The  best  of  all  fixation  apparatus  is  Sayre's 
plaster-of-Paris  jacket  applied  while  the  patient  is  suspended 
(Fig.  249).  The  Sayre  apparatus  applied  in  this  manner  is 
used  for  the  treatment  of  caries  of  the  lumbar  region  and 
the  lower  half  of  the  dorsal  region.  When  all  subjective 
signs  cease  substitute  for  Sayre's  jacket  a  felt  jacket  which 
laces  (Golding-Bird).  Caries  of  the  upper  half  of  the  dor- 
sal region  is  often  treated  by  a  Sayre's  jury-mast  (Fig.  250)  ; 
but  if  the  jury-mast  fails,  it  may  be  necessary  to  place  the 
patient  horizontally  in  "  an  open  cuirass,  fitted  to  the  back 
from  occiput  to  sacrum,  and  combined  with  pulley  extension 
to  the  head  and  pelvis."  ^ 

Spinal  abscesses  are  treated  as  indicated  on  page  593. 
Treves  opens  the  abscess  in  the  loin,  employing  a  vertical 
incision ;  introduces  a  finger,  and  examines  the  anterior  sur- 
face of  the  vertebrae  (if  the  patient  be  young  and  slender  and 
if  the  disease  affects  the  dorsal  or  lumbar  region) ;  irrigates 
with  gallons  of  warm  corrosive-sublimate  solution  (i  :  5000) ; 
scrapes  the  wall  of  the  abscess  with  the  finger  or  rubs  it 
with  a  sponge ;  irrigates  again  ;  scrapes  again,  and  so  on 
until  the  wall  is  cleared  of  debris  ;  wipes  the  abscess  dry, 
and  sutures  without  drainage.  The  patient  remains  recum- 
bent for  months.  It  may  be  necessary  to  repeat  the  oper- 
ation. If  mixed  infection  occurs,  drainage-tubes  must  be 
inserted.  Treves  formerly  removed  the  carious  bone,  but 
many  surgeons  do  not  approve  of  removing  bone.  Halsted 
opens  the  abscess-cavity  widely,  removes  as  much  of  the 
wall  as  possible,  and  packs  with  iodoform  gauze.  Barker 
opens  the  abscess  at  its  lower  portion  and  inserts  an  irri- 
gating curet.  This  instrument  is  a  hollow  gouge  through 
which  hot  water  flows.  He  scrapes  and  irrigates  the  abscess- 
wall  with  this  instrument.  When  the  water  runs  clear  he 
withdraws  the  instrument,  injects  three  ounces  of  iodoform 
emulsion,  and  sutures  the  wound.  Chipault,  Calot,  and 
others  have  advocated  forcible  correction  of  the  deformity 
in  Pott's  disease  without  abscess.  Forcible  correction  is 
only  used,  if  used  at  all,  in  angular  deformity  of  the  mid- 
dle and  lower  part  of  the  dorsal  region.  It  is  not  used  in 
the  cervical,  upper  dorsal,  or  lumbar  region.  Before  it  is 
used  a  skiagraph  should  be  taken,  to  show  if  bony  ankylosis 
exists  or  if  there  is  an  abscess.  If  there  is  an  abscess,  it  must 
be  treated  surgically,  and  must  heal  before  forcible  correction 
is  attempted.    If  bony  ankylosis  exists,  it  must  not  be  broken 

'  Jordan  Lloyd,  in  Birmingham  Medical  Review,  April,  1897. 


704 


SURGERY   OF   THE   SPINE. 


down.  Only  recent  cases  are  suited  for  this  treatment,  and 
only  cases  in  which  very  few  vertebrae  are  involved  (Gabaert). 
The  operation  is  unjustifiable  if  any  organs  are  tubercular, 
and  if  a  patient  is  in  very  poor  health.  It  is  particularly 
indicated  when  the  deformity  interferes  with  respiration  or 
digestion,  or  when  there  is  paraplegia.  The  operation  does 
not  injure  the  cord  or  its  membranes.  The  operation  is  not 
entirely  safe,  and  a  number  of  deaths  have  been  reported. 
Chloroform  must  not  be  given,  as  it  seems  to  possess  special 
dangers  in  this  condition.  Gabaert^  points  out  certain,  dis- 
asters which  may  follow  forcible  correction.  They  are: 
death  during  anesthesia  ;  rupture  of  an  abscess  ;  subsequent 
paralysis  of  the  legs  and  bladder ;  disseminated  tuberculosis  ; 
and  shock  with  convulsions  and  death.  Forcible  correction 
can  be  carried  out  as  follows  :  the  patient  is  anesthetized 
with  ether,  and  is  placed  face  down ;  one  assistant  holds  the 
feet,  another  the  head,  another  supports  the  abdomen,  and 
another  the  pelvis.  While  strong  traction  is  made  on  the 
head  and  feet,  the  surgeon  makes  forcible  pressure  on  the 
projection.  After  the  correction  of  the  deformity  a  plaster- 
of-Paris  support  is  applied  so  as  to  include  the  neck,  trunk, 
and  pelvis,  the  gibbosity  being  left  exposed  in  order  to  avoid 
ulceration.  A  plaster-of-Paris  support  is  used  for  at  least  six 
months.  After  forcible  correction  a  large  gap  exists,  and 
this  does  not  fill  up  with  bone,  but  with  dense  fibrous  tissue, 
and  in  some  cases  the  spines  and  laminae  ankylose.  When  the 
support  is  first  removed,  there  is  usually  a  reappearance  of 
the  deformity  to  some  degree.  In  some  cases  Calot  resects 
the  spines  and  laminae  of  the  diseased  vertebrae,  and  performs 
osteotomy  of  the  ankylosed  vertebral  bodies.^ 

If  paraplegia  is  due  to  disease  of  the  middorsal  region, 
forcible  correction  should  be  attempted.  Some  surgeons 
have  warmly  advocated  laminectomy  in  spinal  caries  para- 
plegia. This  operation  is  rarely  necessary,  but  in  some  few 
cases  is  imperatively  demanded.  Many  cases  recover  from 
paraplegia  without  operation — operation  has  a  very  heavy 
mortality ;  many  are  not  benefited  at  all  by  it,  but  in  some 
cases  it  has  certainly  saved  life. 

Laminectomy  should  not  be  undertaken  until  treatment 
by  rest  and  fixation  has  been  applied  for  at  least  one  year 
(Willard). 

Laminectomy  may  be  necessary  in  cervical  caries  to  pre- 
vent asphyxia.     The  operation  enables  the  surgeon  to  re- 

1  Ann.  de  la  Soc.  Beige,  July  15,  1898. 

2  F.  Calot,  in  Archiv.  Prov.  de  Chirurgie,  Feb.,  1897. 


.  INJURIES   OF  SPINAL    LIGAMENTS  AND   MUSCLES.    705 

move  masses  of  inflammatory  material  which  make  pressure 
on  the  cord.  The  dura  should  not  be  opened  unless  there 
is  evidently  trouble  beneath  it,  in  which  case  it  is  incised  and 
any  tubercular  area  removed,  the  dura  being  subsequently 
sutured.  Menard  removes  the  transverse  processes  of  the 
diseased  vertebrae  and  the  heads  and  necks  of  the  associated 
ribs  in  order  to  give  the  surgeon  access  to  the  diseased  ver- 
tebral bodies. 

During  the  course  of  caries  of  the  spine  have  the  patient 
eat  fat-forming  and  nutritious  food,  try  to  get  him  out  often 
into  the  fresh  air,  and  administer  tonics  and  antitubercular 
drugs.  Sea-air  is  very  beneficial.  When  all  active  disease 
ceases,  and  only  angular  curvature  remains,  use  an  apparatus 
to  combine  extension  with  mechanical  support,  the  plaster 
jacket  being  generally  employed. 

Spondylitis  Deformans. — This  is  the  name  usually 
applied  to  osteo-arthritis  of  the  spine.  In  this  disease  osteo- 
phytic  formation  takes  place  at  the  vertebral  borders,  and 
the  vertebrae  become  ankylosed.  The  vertebral  bodies  as  a 
rule  are  most  affected  by  the  disease,  but  any  portion  of  a 
vertebra  may  be  attacked,  and  often  the  heads  of  the  ribs 
are  anchored  to  the  spine  by  bone. 

The  disease  may  begin  in  infancy,  childhood,  youth,  adult 
life,  or  old  age. 

Symptoms. — There  are  decided  and  persistent  pain  and 
also  tenderness  of  the  spine,  and  occasionally  evidence  of 
pressure  on  the  nerve-roots.  Early  in  the  case  deformity 
is  apt  to  occur,  because  at  -this  period  there  is  inflammatory 
softening.^  The  deformity  is  not  angular,  but  is  usually  a 
total  kyphosis,  the  column  being  bent  forward  from  above 
and  made  into  a  single  curve.    Lateral  curvature  may  occur. 

Treatment. — Cure  is  impossible,  but  amelioration  can  be 
obtained. 

The  local  and  constitutional  treatment  is  as  for  osteo- 
arthritis in  any  region.  If  curvature  begins,  a  mechanical 
support  must  be  applied. 

Injuries  of  spinal  ligaments  and  muscles,  which 
may  complicate  more  serious  injuries  or  may  exist  alone,  are 
caused  by  wrenches,  twists,  and  violent  muscular  efforts  (as 
in  lifting).  Railway  accidents  may  be  responsible  for  these 
sprains  and  strains. 

Syraptoms. — Injuries  of  the  back,  even  without  cord- 
injury,  are  frequently  linked  with  very  deceptive  nervous 
S5^mptoms.      Symptoms  are  often    severe,  but  are   usually 

^  J.  Jackson  Clarke's  book  on  Orthopedic  Surgery. 
45 


706  SURGERY  OF   THE  SPEVE. 

temporary.     In    some    few    cases    the    symptoms    are    per- 
sistent.    Secondary  disease  of  the  cord  is  extremely  rare. 
Any  region  may  be  affected,  but  the  lumbar  is  most  usually 
injured,    and    the    entire    spine    may    suffer.      The    three 
marked    symptoms    are    pain,   tenderness,   and    stiffness   of 
the  back.     At  the  time  of  injury,  and  for  a  time  after,  there 
is  often  marked  shock,  and  hysterical  excitement  is  occa- 
sionally observed.     The  cardinal  symptoms  may  arise  very 
soon,  but  may  not  become   severe  for  a  day  or  two.     The 
pain  is  not  acute  when  at  rest,  but  becomes  acute  on  move- 
ment.^    The  pain  is  felt  in  the  back,  and  sometimes  darts  into 
the  extremities.    The  muscles  of  the  back  are  rigid,  the  spasm 
being    due   to    pain.     The    patient    is    very    careful    not  to 
twist   or  bend  the   spine,  because   to   do  so   increases  pain. 
In   a    one-sided  injury  the    rigidity   is    unilateral,  and   this 
symptom  cannot  be  simulated.      Often,  but  by   no  means 
always,  the  region  of  the  back  is  swollen  and  the  skin  is 
discolored.     The  tenderness  is  not  of  the  skin,  but  of  the 
muscles.     Firm  pressure  on  a  spot  of  real  tenderness  causes 
rapid  pulse  (Mannkopff).     The  vertebral  spines  are  regular 
and    are    not    mobile.      There    is    no    distant    paralysis    or 
hyperesthesia  unless  the  cord  is  damaged  (though  in  some 
rare  cases  the  bladder  and  the  rectum  are  paralyzed   when 
no  cord-lesion  can  be  detected,  and  hyperesthesia  may  exist 
over  the  spines).     Moullin  tells  us  that  the  extremities  feel 
weak  because  they  are  deprived  of  proper  support  on  account 
of  the  immobility  of  the  muscles  of  the  back.       For  the 
same  reason  the  action  of  the  abdominal  muscles  is  inter- 
fered with,  and  the  power  of  micturition  and  of  defecation 
is  impaired  (there  are  constipation  and  difficulty  in  emptying 
the  bladder). 

The  treatment  of  recent  injuries  comprises  rest;  the  ap- 
plication of  an  ice-bag  and  leeching  over  the  painful  area. 
After  a  day  or  two  hot  fomentations,  tincture  of  iodin,  and 
inunctions  of  ichthyol  and  lanolin  are  used ;  and,  later  still, 
massaee,  douches,  and  frictions  with  a  stimulating  liniment 
are  employed.  Phenacetin  helps  to  relieve  pain,  though  m 
some  cases  opium  is  necessary.  The  injury  is  called  "rail- 
way spine  "  when  it  is  caused  by  a  railway  accident. 

After  the  immediate  effects  of  the  accident  subside  trau- 
matic neurasthenia  is  apt  to  arise.  In  this  condition  the 
patient  grows  tired  easily  and  complains  of  pains  and  aches 
in  the  back  and  loins,  interfering  with  or  preventing  work ; 
paresthesia    and  numbness  exist  in  the  extremities  ;  in  many 

1  Moullin  on  Sprains. 


IXJCHIES   OF  SPIXAL    LIGAMENTS  AND   MUSCLES.     Joy 

cases  sexual  intercourse  is  impossible  because  of  premature 
ejaculation  or  of  incapacity  for  erection  ;  there  are  dyspepsia, 
eye-strain,  insomnia,  loss  of  memory,  rapid  and  irregular 
pulse,  cardiac  palpitation,  and  mental  depression  or  con- 
fusion. The  reflexes  are  usually  exaggerated,  but  they  can 
be  exhausted  more  easily  than  can  the  exaggerated  reflexes 
of  organic  cord  disease  (because  of  irritable  weakness).  Some 
rigidity  and  tenderness  exist  in  the  back,  and  the  skin  over 
this  region  is  often  hyperesthetic.  Attacks  of  retention  of 
urine  may  occur.     Hypochondria  is  not  unusual. 

Treatment  of  Traumatic  NeicrastJicnia. —  Employ  rest, 
tonics,  massage,  douches,  and  frictions  to  the  back.  Secure 
sleep,  and  endeavor  to  bring  about  a  gain  in  weight.  If 
sexual  incapacity  or  seminal  emissions  worry  the  patient, 
dilate  the  urethra  with  steel  bougies. 

Traumatic  hysteria  develops  only  in  those  predisposed  by 
a  neuropathic  hereditary  tendency ;  traumatic  neurasthenia 
may  arise  in  anybody.  In  the  first  disease  the  accident  is 
only  the  exciting  cause ;  in  the  second  disorder  it  is  the 
cause.  Many  cases  of  so-called  "  railway  spine  "  are  really 
examples  of  traumatic  hysteria.  Traumatic  hysteria  and 
neurasthenia  may  be  associated.  Neurasthenia  is  a  con- 
dition of  exhaustion  associated  with  a  number  of  chronic 
disorders  ;  it  forms  a  foundation  on  which  hysteria  is  apt 
to  build  its  structure.  The  structure  of  hysteria  is  made  up 
of  morbid  impressionability,  hyperesthesia  of  centers,  low- 
ered self-control,  and  sensitiveness  of  the  peripheral  nervous 
system.  The  accident  plays  a  double  part  in  producing  trau- 
matic hysteria  :  first,  by  its  effect  on  the  mind  (psychical  trau- 
matism) ;  second,  by  its  effect  on  the  body,  which  anchors  the 
attention  to  one  point.  An  area  of  pain  or  stiffness  often 
serves  as  an  autosuggestion  which  undergoes  morbid  magnif- 
ication when  viewed  through  the  distorting  medium  of  hysteria. 
Erichsen  taught  that  the  symptoms  of  what  he  named  "  rail- 
way spine  "  arose  from  inflammation  of  the  cord  and  its  mem- 
branes, a  view  now  abandoned.  A  blow  given  to  a  hysterical 
person  causes  a  feeling  of  numbness,  and  thus  negative  sen- 
sation from  local  shock  may  establish  the  idea  of  paralysis, 
or  the  traumatism,  acting  as  a  suggestion,  may  inhibit  motor 
representations  and  destroy  the  normal  ideas  of  motion  and 
feeling  (Charcot  and  Pitre).  Terror  always  causes  a  feeling 
of  loss  of  power  in  the  legs,  and  the  terror  of  the  accident 
may  thus  develop  the  idea  of  paraplegia.  The  site  of  a  trau- 
matism may  localize  symptoms  ;  for  instance,  a  blow  upon 
the  eye  may  cause  amaurosis  or  blepharospasm.     It  is  im- 


708  SURGERY   OF   THE   SPINE. 

portant  to  remember  Charcot's  saying  that  a  hysteria  long 
latent  and  unrecognized  may  be  awakened  into  obvious 
activity  by  a  blow  or  an  accident.  Pitre  shows  the  same  to 
be  true  of  epilepsy.  A  not  unusual  lesion  is  hysterical  trau- 
matic monoplegia,  not  coming  on  at  once  after  the  accident, 
but  usually  some  days  afterward,  and  presenting  flaccid  mus- 
cles, the  electrical  reactions  and  reflexes  remaining  normal, 
but  the  muscular  sense  being  lost  (Pitre).  The  muscles 
usually  waste.  The  skin  of  the  paralyzed  limb  is  anesthetic 
or  analgesic.  There  may  be  anesthesia  limited  to  a  limb, 
hemianesthesia,  or  general  anesthesia.^  Hysterical  paraly- 
sis is  usually  associated  with  the  permanent  stigmata  of 
hysteria — concentric  contraction  of  the  visual  field,  pharyn- 
geal anesthesia,  convulsive  seizure,  and  hysterogenic  zones 
(Clarke  and  Pitre).  The  permanent  stigmata  may  be  latent. 
Hysterical  phenomena  lack  regularity  of  evolution,  and  they 
may  be  produced,  altered,  or  abolished  by  mental  influences 
or  by  physical  forces  which  produce  no  effect  on  organic 
disease.  In  most  hysterical  conditions  the  general  health  is 
not  profoundly  impaired.^ 

Treatment. — By  moral  means  chiefly.  Gain  the  confidence 
of  the  patient.  In  many  cases  separation  from  family  and 
friends  is  necessary  and  isolation  is  desirable.  The  Weir 
Mitchell  rest-cure  is  the  best  plan  of  treatment,  and  all  its 
details  should  be  carried  out  faithfully. 

Maling-ering. — Persons  often  pretend  to  suffer  from  mala- 
dies as  a  result  of  accident  which  diseases  do  not  exist  in  them. 
Some  get  well  upon  the  rendering  of  a  favorable  verdict  by  a 
jury.  In  any  case  always  examine  carefully,  so  as  to  be  able 
to  exclude  malingering.  Note  the  patient's  behavior  and 
motions  when  his  attention  is  diverted  from  his  disease. 
Meningomyelitis  can  be  excluded  if  there  be  no  spasm, 
paralysis,  hyperesthesia,  paresthesia,  or  anesthesia  at  a  dis- 
tance (A.  Pearce  Gould).  If  pain  has  lasted  for  months, 
if  pressure  downward  upon  the  head  or  shoulders  does  not 
increase  pain,  if  the  vertebrae  are  movable,  and  there  is  no 
angular  displacement,  exclude  caries.  Gould  states  that 
when  there  are  wasted  muscles,  when  moderate  spine-move- 
ment is  painless,  but  effort  in  bringing  the  body  erect  causes 
pain  in  the  erector  spinae  region,  the  trouble  is  a  strain  of 
the  erector  spinae  muscle.  If  the  muscle  is  not  wasted,  and 
the  pain  is  in  bending  forward  rather  than  in  straightening 
up,  the  vertebral  ligaments  are  the  seat  of  trouble.     Unilateral 

'  j.  Mitchell  Clarke,  in  Brain. 

-  Read  the  works  of  Thorburn  and  Pitre. 


COMPRESSION   OF   THE   SFfX.lL    COED.  709 

Spasm  cannot  be  simulated.  The  administration  of  ether  may 
dispose  of  a  pretended  paralysis,  the  patient  moving  the  sus- 
pected extremity  while  drunk  from  the  anesthetic. 

Concussion  of  the  Spinal  Cord. — This  term  has  no 
definite  pathological  meaning.  It  is  probable  that  the  condi- 
tion is  one  of  laceration  of  capillaries  and  of  cord-substance. 

The  symptoms  are  shock,  intense  pallor,  nausea,  often 
vomiting,  and  sometimes  syncope.  With  this  condition  special 
symptoms  may  be  linked — as  temporary  paralysis,  a  girdle- 
sensation,  numbness  and  loss  of  power  in  the  limbs,  hiccough, 
torticollis,  coarse  tremors,  pains  in  the  back  and  limbs,  areas 
of  anesthesia  and  analgesia — depending  on  the  portion  of 
cord  lacerated. 

Treatment. — The  treatment  in  concussion  of  the  spinal 
cord  is  the  same  as  that  for  sprains.  Traumatic  neurasthenia 
and  hysteria  or  organic  cord-disease  may  follow  this  injury. 

Contusion  of  the  spinal  cord  may  arise  from  a  blow 
or  a  sprain,  but  it  is  usually  due  to  extreme  flexion  ot  the 
spine.  It  causes  hemorrhage  into  the  gray  matter  of  the 
cord  (hematomyelia).  The  symptoms  are  motor  and  sen- 
sory palsy  and  diminished  reflexes.  Some  cases  recover, 
but  others  end  in  myelitis. 

Wounds  of  the  spinal  cord  are  rare,  and  are  usually 
fatal.  Wounds  above  the  origin  of  the  phrenic  nerves  cause 
almost  instant  death.  Gunshot-wounds  are  the  most  usual 
form,  the  cord  being  damaged  by  the  bullet  and  by  bone- 
fragments.  A  knife  is  sometimes  thrust  in  between  the 
occiput  and  atlas. 

Compression  of  the  spinal  cord  may  be  due  to  blood 
or  to  inflammatory  exudate.  Compression  from  blood  may 
be  due  to  extra^yiedullary  hemorrhage  or  to  intramedullary 
hemorrhage.  Extramedidlary  hemorrhage  causes  sudden 
pain  in  the  back,  the  pain  radiating  from  compressed  nerve- 
roots  ;  hyperesthesia  and  paresthesia  in  the  area  of  the  radi- 
ated pain ;  spasm  of  vertebral  muscles  supplied  by  the 
compressed  nerves,  sometimes  of  muscles  whose  nervous 
supply  is  below  the  lesion ;  tremors ;  convulsions ;  reten- 
tion of  urine ;  paralytic  symptoms  following  the  signs  of 
irritation,  but  no  absolute  paralysis  (Mills).  A  girdle-sen- 
sation is  usual.  Intramedullary  hemorrhage  causes  pain,  a 
girdle-sensation,  abolition  of  reflexes,  and  paralysis.  Spasms, 
rigidity,  and  paralysis  come  on  early.  Bed-sores  may  form, 
and  retention  of  urine  and  incontinence  of  feces  may  be 
observed.  Paralysis  from  hemorrhage  is  gradually  pro- 
gressive from  below  upward  (crawling  paralysis). 


7IO  SURGERY  OF   THE   SPINE. 

Treatment. — If  paralysis  from  spinal-cord  bleeding  ex- 
tends rapidly,  and  life  is  endangered  through  the  probable 
involvement  of  a  vital  center,  perform  a  laminectomy,  remove 
the  clot,  and  arrest  the  hemorrhage.  It  is  wise  to  always 
open  the  dura  and  inspect  the  cord.  Extramedullary  hem- 
orrhage may  be  arrested  by  sutures  or  by  packing.  Intra- 
medullary hemorrhage  may  be  arrested  by  a  suture-ligature 
or  by  packing.  If  an  extramedullary  clot  is  extensive,  it  is 
proper  to  make  a  second  laminectomy  near  the  lower  end 
of  the  spinal  column  in  order  to  permit  the  surgeon  to  thor- 
oughly wash  it  out.  The  dura  must  be  sutured  and  drainage 
is  to  be  employed.  If  there  is  paraplegia,  complete  anesthe- 
sia of  the  paralyzed  parts  and  entire  abolition  of  the  deep 
reflexes,  operation  is  useless  because  the  cord  is  destroyed. 
In  some  cases  with  persistent  paraplegia  the  operation  should 
be  undertaken.  If  operation  is  not  undertaken,  have  the 
patient  to  lie  upon  his  side  and  give  morphin  hypodermat- 
ically.  If  hemorrhage  continues  in  the  cord  and  if  the  patient 
be  plethoric,  perform  venesection.  Some  surgeons  advise 
hypodermatic  injections  of  ergotin.  To  promote  absorption 
of  the  clot  and  exudate  give  a  combination  of  carbonate  and 
acetate  of  ammonium,  order  pilocarpin,  and  employ  spinal 
galvanism  and  hot  douches  (Bartholow). 

Fractures  and  dislocations  of  the  spine  are  very  rare. 
The  spinal  regions  most  liable  to  injury  are  the  atlo-axial, 
the  cervicodorsal,  and  the  dorsolumbar  (Treves).  A  verte- 
bra may  be  fractured  alone,  but  dislocation  without  fracture, 
except  in  the  upper  cervical  region,  very  rarely  occurs. 
These  two  lesions,  dislocation  and  fracture,  are  so  often 
associated  that  the  term,  fracture-dislocation  is  used  by  many 
surgeons  to  include  them  both.  The  causes  of  fracture  and 
dislocation  are  direct  force  (rarely)  and  indirect  violence 
(commonly).  Fracture-dislocation  from  direct  force  may 
occur  at  any  part  of  the  column,  and  in  this  accident  the 
posterior  vertebral  segments  are  driven  together,  and  the 
cord,  as  a  rule,  escapes  injury.  Fracture-dislocations  from 
indirect  force  most  commonly  happen  in  the  cervical  and 
dorsal  regions.  In  the  cervical  region  reduction  can  usually 
be  secured,  but  in  the  lumbar  region  reduction  is  impos- 
sible. In  fractures  from  indirect  force  the  cord  generally 
suffers. 

Symptoms. — In  fracture-dislocation  much  displacement 
is  rare,  but  some  is  almost  always  recognizable  (irregular- 
ity of  the  spines  or  angular  deformity).  There  are  pain 
(which  is  increased  on  motion),  tenderness,  ecchymosis,  an^ 


FRACTURES  AND   DISLOCATIONS   OF   THE   SPINE.    71I 

motor  and  sensory  paralyses.  Priapism,  cystitis,  and  reten- 
tion of  urine  often  occur.  Horsley  has  pointed  out  that 
in  many  cases  paralysis  passes  away  only  to  subsequently 
recur,  the  recurrence  being  due  to  edema  of  the  cord.  In 
some  cases  of  spinal  injury  there  is  temporary  paralysis  due  to 
shock.  Persistent  paralysis  may  be  due  to  laceration  of  the 
cord  or  compression  of  the  cord  by  bone,  blood-clot,  or  prod- 
ucts of  inflammation.  In  total  division  of  the  cord  the  deep 
reflexes  are  abolished,  anesthesia  exists,  and  there  is  motor 
and  vasomotor  paralysis.  The  extent  of  paralysis  depends 
on  the  seat  of  the  cord-injury.  The  prognosis  depends  on 
the  amount  of  damage  done  to  the  cord.  Fracture-disloca- 
tions in  the  cervical  region  produce  obvious  deformity,  stiff- 
ness of  the  neck,  and  irregularity  of  the  spines,  and  a  dis- 
placed vertebra  may  occasionally  be  detected  by  a  finger  in 
the  pharynx.  Crepitus  can  rarely  be  detected  unless  a 
spinous  process  is  fractured.  The  Rontgen  rays  aid  diag- 
nosis. 

Treatment  of  Fracture-dislocations. — When  dislocation 
of  the  body  of  a  vertebra  obviously  exists,  the  surgeon  may 
attempt  reduction  by  extension  and  rotation  (White).  The 
maneuver  is  very  dajagerous  in  the  cervical  region,  and,  as 
deaths  have  happened,  some  eminent  surgeons  advise  against 
reduction  when  the  injury  affects  that  region.  In  fracture- 
dislocation  the  traditional  plan  is  to  straighten  the  spine, 
gently  if  possible,  and  to  put  the  patient  upon  his  back 
upon  a  water-bed  or  upon  air-cushions.  In  fractures  in 
the  cervical  region  support  the  head  and  neck  with  sand- 
bags. Empty  the  bladder  every  six  hours  with  a  soft 
catheter,  which  is  kept  strictly  aseptic.  Take  every  pre- 
caution to  prevent  bed-sores.  Some  surgeons  advocate 
reduction  of  the  deformity  by  extension  and  counter-ex- 
tension, and  the  application  of  a  firmly-fitting  but  remov- 
able jacket  with  the  suspension  collar  (as  used  in  Pott's 
disease).  If  this  plan  is  employed,  the  head  of  the  bed  is 
raised  and  the  collar  is  fastened  to  it.  Every  day  exten- 
sion is  made  gently  from  the  shoulders  in  dorsolumbar 
fracture,  and  from  the  chin  and  occiput  in  cervical  fractures. 
Extension  may  be  maintained  permanently  until  cure. 
White  says  laminectomy  should  be  performed  for  fracture 
or  for  dislocation  when  there  is  obvious  depression  of  the 
vertebral  arches  ;  in  all  cases  of  pressure  upon  the  cauda 
equina ;  when  there  are  characteristic  symptoms  of  spinal 
hemorrhage ;  and  in  some  cases  where  rapid  degeneration 
becomes  manifest.     Surgeons,  as  a  rule,  agree  that  operation 


712  SURGERY  OF  THE   SPINE. 

will  be  useless  when  there  are  motor  paralysis,  comp.lete_ 
persistent  anesthesia,  and  entire  loss  of  deep  reflexes,  because 
these  symptoms  indicate  that  total  division  of  the  cord  has', 
taken  place.  It  is  useless  to  operate  for  fracture-dislocation 
of  the  atlas  or  axis.  In  ordinary  cases  of  fracture-disloca- 
tion below  the  axis  in  which  the  cord  is  not  completely 
divided  treat  by  extension  for  six  or  eight  weeks,  and  then 
operate  if  the  case  is  not  improving.  In  hemorrhagic  cases, 
or  cases  with  marked  depression  of  the  arches,  operate  early. 
If  signs  of  degeneration  begin  within  six  or  eight  weeks, 
operate  at  once.  "  In  compound  fractures,  in  injuries  of  the 
laminae  and  spinous  processes  without  a  complete  crush  of 
the  cord,  when  symptoms  are  due  to  hemorrhage,  when 
pachymeningitis  arises,  if  the  cauda  equina  is  compressed, 
operate"  (Thorburn). 

Operations  on  the  Spine. — Operations  for  Spina 
Bifida. — Mayo  Robson  maintains  ^  that  operation  is  not  de- 
manded when  the  sac  is  of  small  size  and  is  well  protected 
by  sound  integument ;  that  operation  is  improper  when  a 
large  portion  of  the  column  is  fissured,  or  when  paraplegia 
or  hydrocephalus  exists ;  that  operation  is  advisable  only 
in  meningocele,  in  cases  in  which  the  integument  is  thin  and 
translucent,  in  cases  in  which  the  cord  is  flattened  out,  or  the 
nerves  are  fused.  Robson  has  closed  the  osseous  defect  by 
transplanting  periosteum. 

Instruments  Required. — Scalpels,  dissecting-  and  hemo- 
static forceps,  scissors,  rongeur  forceps,  dural  separator, 
Hagedorn  needles  and  needle-holder,  silk,  silkworm-gut  or 
catgut. 

Operation. — Surround  the  sac  by  elliptical  incisions.  Find 
the  neck  of  the  sac,  and  if  it  contains  no  visible  nerves  ligate 
it  and  cut  off  the  protrusion.  Push  the  stump  into  the  canal. 
Freshen  the  bone-margins  and  spring  a  piece  of  celluloid 
beneath  them  to  close  the  gap  (Park).  Suture  over  the 
stump  with  small  sutures  of  catgut.^ 

Treves's  Operation  for  Vertebral  Caries  (page  S93). 

Laminectomy. — The  instruments  required  in  laminectomy 
are  dissecting-,  rat-toothed,  and  hemostatic  forceps  ;  scalpels  ; 
bone-cutting  forceps;  rongeur  forceps;  a  dry  dissector ;  a 
periosteum-elevator ;  sequestrum-forceps ;  small  scissors, 
straight  and  curved  on  the  flat;  a  chisel  and  mallet;  re- 
tractors ;  blunt  hooks  ;  a  probe  ;  tenaculum-forceps  ;  a  spoon- 

'  Annals  of  Surgery,  vol.  xxii.,  No.  i. 

2  A  full  consideration  of  the  various  plans  of  operating  will  be  found  in  an 
article  by  Marcy,  in  Annals  of  Surgery,  March,  1895. 


FOREIGN  IWDIES  IN   THE   NOSE.  713 

curet ;  a  sand-pillow  ;  fine  needles,  curved  and  straight,  large 
needles,  and  a  needle-holder. 

In  the  operation  of  laminectomy  the  patient  lies  prone 
and  a~sand-piriow  IS  placed  under  the  lower  ribs.  Make  a 
vertical  incision  over  and  down  to  the  vertebral  spines,  the 
middle  of  the  incision  corresponding  to  the  seat  of  injury 
or  disease.  The  sides  of  the  spinous  processes  and  the  laminae 
are  cleared.  The  periosteum  is  incised  in  the  angle  between 
the  laminae  and  spines,  and  is  lifted  away  from  the  arch. 
The  spinous  processes  are  cut  off  close  to  their  bases  by 
means  of  rongeur  forceps,  the  laminae  are  removed  on  each 
side  with  the  rongeur,  and  the  dura  is  exposed.  In  some 
cases  of  fracture  fragments  will  be  found  on  exposing  the 
vertebra,  or  a  blood-clot  will  be  seen  between  the  dura  and 
the  bone;  in  other  cases  the  dura  must  be  opened  with 
scissors  vertically  in  the  middle  line  while  it  is  grasped  with 
rat-toothed  forceps.  After  reaching  and  removing" the  com- 
pressing cause,  or  after  failing  to  find  or  remove  it,  close 
the  dura  with  catgut,  drain  the  length  of  the  wound  with  a 
tube,  stitch  the  superficial  parts  with  silkworm-gut,  and  dress 
antisepticaliy. 

Puncture  of  the  spinal  meninges,  or  lumbar  puncture, 
was  devised  by  Quincke,  and  has  been  carefully  tested  by 
many  surgeons  (Furbringer,  Naunyn,  and  others).  It  is 
employed  as  a  means  of  diminishing  cerebral  pressure  in 
hydrocephalus,  cerebral  tumor,  uremia,  and  tubercular  men- 
ingitis. It  has  proved  of  little  therapeutic  value.  In  some 
cases  the  examination  of  the  fluid  has  been  of  diagnostic 
value.  Stadelmann  has  reported  37  cases  in  which  tubercle 
bacilli  were  found  in  the  fluid.'  Turbidity  of  the  fluid  indi- 
cates the  existence  of  meningitis.  The  back  is  sterilized  ;  the 
patient  may  lie  prone,  with  a  pillow  under  the  belly,  or  may 
sit  in  a  chair,  with  the  body  bent  forward ;  no  anesthetic  is 
required.  A  Pravaz  syringe  is  employed,  and  the  point  is  in- 
serted at  the  under  surface  of  a  spinous  process.  In  some 
cases  but  a  fev/  drops  of  fluid  will  be  obtained,  in  other 
cases  several  ounces  may  be  removed.  ^r-*— * —     ^  0  \ 

XXV.  SURGERY  OF  THE  RESPIRATORY  ORGANS. 

I.  Diseases  and  Injuries  of  the  Nose  and  Antrum. 

Foreign  bodies  in  the  nose  are  usually  introduced 
through  the  anterior  nares,  but  in  rare  instances  they  enter 
by  way  of  the  posterior  nares.     Small  particles  are  often 

1  Berliner  klinische  Wochenschrift,  July  8,  1895. 


714         SURGERY  OF  THE   RESPIRATORY  ORGANS. 

expelled  spontaneously ;  larger  pieces  collect  mucus  and 
epithelium  and  become  fixed.  Some  materials  swell  after 
lodgement. 

Treatment. — In  many  cases  anesthesia  is  required.  Illu- 
minate the  nostril,  and,  if  the  foreign  body  can  be  seen, 
insert  a  hook  back  of  it  and  effect  its  removal  by  means 
of  forceps.  Some  foreign  bodies  require  to  be  pushed  back 
into  the  nasopharynx.  Occasionally  expulsion  may  be 
effected  by  inserting  a  rubber  tube  into  the  unblocked  nostril 
and  telling  the  patient  to  blow  forcibly  through  the  tube.  In 
serious  cases  a  specialist  should  be  summoned  to  remove  a 
portion  of  the  turbinated  bone  or  to  perform  whatever  opera- 
tion he  thinks  best. 

Inflammation  and  Abscess  of  the  Antrum  of 
Highmore  (Maxillary  Antrum). — The  source  of  this 
disease  may  be  inflammation  of  the  nose  or  periostitis  around 
the  roots 'of  the  teeth.  In  some  cases  the  opening  into  the 
nose  is  patent ;  in  other  cases  it  is  partly  or  completely  blocked. 
Caries  and  necrosis  may  arise.  The  symptoms  are  pain, 
edematous  swelling  of  the  face,  and  thinning  of  the  bone  so 
that  it  may  crepitate  under  pressure.  When  pus  has  formed, 
if  the  antral  opening  is  patent,  certain  positions  of  the  head 
will  cause  a  purulent  flow  from  the  nose,  and  if  a  speculum  is 
inserted  pus  may  be  seen  as  it  flows  into  the  nose.  The  open- 
ing of  the  maxillary  antrum  into  the  nasal  channel  is  at  the 
summit  of  the  antrum  ;  hence  the  antrum  drains  when  the 
head  is  inverted.  The  ethmoidal  cells  and  frontal  sinus  drain 
best  when  the  patient  is  upright.  Wipe  the  interior  of  the 
nose  and  place  the  patient  with  his  head  between  his  knees. 
If  the  nostril  fills  with  pus,  it  comes  from  the  antrum  (Cobb). 
In  severe  cases  the  jaw  expands,  the  eye  protrudes,  and  great 
tenderness  of  the  alveolus  exists.  Percussion  exhibits  a  dull 
note.  In  making  a  diagnosis  it  is  well  to  take  the  patient  into 
a  dark  room,  insert  an  electric  light  into  the  mouth  and  note 
the  diminution  of  light-transmission  on  the  diseased  side  as 
contrasted  with  the  sound  side.  Transillumination  may  be 
easily  practised  by  the  use  of  a  cautery  electrode,  protected 
by  a  small  glass  vial.  Any  cautery  battery  may  be  employed 
(plan  suggested  by  Ohls).  Exploratory  puncture  will  settle 
a  doubtful  diagnosis.  This  may  be  by  way  of  the  lower 
meatus,  the  canine  fossa,  or  the  alveolar  process.^ 

Treatment. — Before  pus  forms  order  the  use  of  hot  fomen- 
tations and  remove  any  diseased  teeth.  When  pus  has  formed 
evacuate  it  at  once.     Before  performing  a  severe  operation  try 

1  Cobb,  in  Boston  Med.  and  Surg.  Joia-.,  May  7,  1896. 


EDEMA    OF  THE   LARYNX.  715 

the  effect  of  opening  into  the  antrum  from  the  nose,  by  means 
of  Krause's  trocar,  followed  by  insufflation  of  iodoform.  If 
this  procedure  fails,  other  means  may  be  employed.  If 
the  disease  arises  from  a  carious  tooth,  pull  the  tooth  and 
push  a  trocar  through  its  socket  into  the  antrum.  If  the  teeth 
are  sound,  bore  a  hole  with  a  large  gimlet  or  with  a  bone- 
drill  above  the  root  of  the  second  bicuspid  tooth  and  one 
inch  above  the  edge  of  the  gum.  A  counter-opening  should 
be  made  into  the  inferior  nasal  meatus.  A  drainage-tube  is 
pulled  from  the  first  opening  into  the  nose  and  is  allowed  to 
protrude  from  the  nostril.  Irrigate  daily  with  peroxid  of 
hydrogen.  In  three  or  four  days  discontinue  through-and- 
through  drainage,  but  prevent  the  first  opening  closing 
until  the  discharge  ceases  to  be  purulent.  In  severe  cases 
make  a  free  incision  through  the  canine  fossa  by  means  of  a 
chisel. 

Distention  and  Abscess  of  the  Frontal  Sinus. — 
The  usual  cause  is  an  injury  which  may  long  antedate  the 
symptoms.  This  injury  causes  or  leads  to  blocking  of  the 
infundibulum ;  secretion  accumulates  and  distends  the  sinus ; 
and  in  some  cases  pus  forms.  In  many  cases  the  fluid  slowly 
accumulates,  and  it  requires  years  to  produce  marked  symp- 
toms. In  other  cases  infection  takes  place,  and  the  symptoms 
are  positive  and  violent.  If  the  outlet  into  the  nose  is  not 
permanently  blocked,  the  fluid  may  discharge  itself  from  time 
to  time.  In  the  chronic  cases  there  is  rarely  much  pain.  The 
chief  sign  is  a  swelling  of  the  inner  or  upper  part  of  the  orbit, 
which  swelling  progressively  increases  in  size  and  displaces 
the  eye.  If  at  any  time  acute  symptoms  supervene,  there 
will  be  pulsatile  pain,  discoloration,  and  tenderness. 

Treatment. — In  some  cases  it  is  possible  to  pass  a  trocar 
upward  from  the  nose  into  the  sinus,  and  so  drain  and  irri- 
gate. In  most  cases  an  incision  should  be  made  through  the 
soft  parts,  and  the  sinus  opened  by  a  trephine  or  chisel.  After 
the  sinus  has  been  opened  it  must  be  curetted,  the  opening 
into  the  meatus  should  be  restored  and  enlarged,  and  a 
drainage-tube  is  to  be  passed  from  the  forehead  incision  into 
the  nostril.  Some  surgeons  open  the  sinus  by  making  an 
osteoplastic  flap  in  the  anterior  wall. 

2.  Diseases  and  In'juries  of  the    Larynx  and  Trachea. 

Bdema  of  the  I^arynx  (Edema  of  the  Glottis). — The 
causes  of  edema  of  the  lar}'nx  are — acute  laryngitis ;  chronic 
diseases,  such  as  tuberculosis,  mahgnant  disease,  or  syphilis; 


7l6  SURGERY  OF   THE    RESPIRATORY   ORGANS. 

inflammatory  disorders,  such  as  diphtheria  and  erysipelas  ; 
acute  infectious  diseases;  Bright's  disease;  aneurysm  ;  whoop- 
ing-cough ;  pneumonia;  quinsy;  wounds  of  the  larynx; 
wounds  of  the  neck ;  scalds  and  burns  of  the  larynx,  and 
the  inhalation  of  irritating  vapors,  such  as  those  of  ammonia 
and  sulphur.  The  symptoms  are  sudden  and  rapidly  increas- 
ing dyspnea,  respiratory  stridor,  huskiness  of  the  voice,  and 
finally  aphonia.  The  swollen  epiglottis  may  be  felt  with  the 
finger  and  may  be  seen  with  the  help  of  a  mirror. 

Treatment. — In  cases  in  which  edema  of  the  larynx  is 
not  excessively  acute,  introduce  a  gag  between  the  teeth, 
hold  the  mouth  open,  take  a  knife  wrapped  to  within  one- 
quarter  of  an  inch  of  its  point,  make  multiple  punctures  into 
the  epiglottis,  and  favor  bleeding  by  the  inhalation  of  steam. 
In  severe  cases  perform  intubation  or  tracheotomy. 

Wounds  and  Injuries  of  the  I/arynx.— The  larynx 
may  be  injured  internally  by  foreign  bodies,  and  externally 
by  blows  and  cuts.  A  condition  often  met  with  is  ait  throat, 
the  result  usually  of  a  suicidal  attempt  on  the  part  of  the 
patient  or  a  homicidal  effort  on  the  part  of  an  assailant. 
The  cut  of  the  suicide  is  usually  in  front ;  as  a  rule,  it  misses 
the  great  vessels,  but  divides  the  cricothyroid  or  thyrohyoid 
membrane.  The  epiglottis  may  be  incised,  or  even  be  cut 
off  If  a  large  vessel  is  cut,  death  rapidly  occurs.  The  im- 
mediate dangers  of  cut  throat  are  hemorrhage,  suffocation 
by  blood  in  the  windpipe  and  bronchi,  or  by  displacement 
of  parts,  and  entrance  of  air  into  veins.  The  secondary 
dangers  are  pneumonia,  infection  and  sepsis,  exhaustion,  and 
secondary  hemorrhage.  The  remote  dangers  are  stricture 
and  fistula  (Keetley). 

Treatment. — In  wounds  of  the  throat  arrest  hemorrhage, 
remove  clots  from  the  larynx  and  trachea,  bring  about  reac- 
tion, asepticize  the  parts  as  well  as  possible,  suture  the  deeper 
structures  with  silver  wire,  catgut,  or  kangaroo-tendon,  and 
the  superficial  parts  with  silkworm-gut,  dress  antiseptically, 
and  place  a  bandage  around  the  head  and  chest  so  as  to 
pull  the  chin  toward  the  sternum.  If  laryngeal  breathing  is 
much  interfered  with,  perform  tracheotomy.  Feed  the  patient 
through  a  tube  until  union  is  well  advanced.  The  old 
method  of  leaving  the  wound  open  is  to  be  condemned. 
When  sutures  are  used  primary  union  may  be  obtained. 
This  fact  was  proved  by  Henry  Morris. 
Scalds  of  the  Glottis  (see  p.  914). 
Foreign  Bodies  in  the  Air-passages. — The  lodge- 
ment of  foreign  bodies  in  the  air-passages  is  a  frequent  acci- 


FOREIGN  BODIES   IN   THE   AIR-PASSAGES.  717 

dent.  Small  solid  bodies  are  usually  expelled  by  coughing. 
Liquids  and  solids  rarely  pass  beyond  the  larynx  (except  in 
laryngeal  disease  or  palsy,  wounds  of  the  floor  of  the  mouth, 
cut  throat,  and  in  people  unconscious  or  very  drunk).  In 
vomiting  during  or  after  the  administration  of  an  anesthetic, 
or  in  the  vomiting  of  drunkards,  the  vomited  matter  may 
find  its  way  into  the  laiynx  or  lungs.  There  is  great  danger 
of  this  accident  in  an  operation  upon  a  patient  with  intestmal 
obstruction  who  has  stercoraceous  vomiting.  In  most 
instances  of  foreign  bodies  lodged  in  the  air-passages  it  will 
be  found  that  the  object  was  being  held  in  the  mouth  when 
a  sudden  deep  inspiration  was  taken  (often  during  laughter). 
The  symptoms  are  immediate,  due  to  obstruction  by  the 
body  and  to  spasm,  and  secondary,  due  to  the  situation  of 
the  body  and  the  changes  it  undergoes  or  induces. 

Lodgement  in  the  pharynx  causes  violent  dyspnea.     The 
body  can  be  seen  or  felt. 

Lodgement  in  the  Larynx.— \n  a  severe  case  the  patient 
fights  madly  for  air  ;  his  face  becomes  livid  and  cyanotic  ;  his 
veins  stand  out  prominently;  speech  is  impossible,  though 
he  may  make  noises  and  utter  harsh  cries;  violent  coughing 
begins,  and  then  vomiting ;  he  tries  to  force  a  finger  down 
his^thr'oat  and  clutches  at  his  neck;  sweat  pours  from  him; 
he  feels  a  sense  of  impending  dissolution,  and  he  falls 
unconscious,  with  incontinence  of  feces  and  urine.^  In  a 
less  severe  case  violent  dyspnea  gradually  departs  and  the 
patient  lies  exhausted ;  but  dyspnea  and  cough  are  liable  to 
recur  suddenly  at  any  time  because  of  spasm,  and  they  may 
be  induced  by  a  change  of  position.  These  attacks  of  fierce 
spasmodic  cough  are  not  at  first  linked  with  expectoration, 
but  after  inflammation  begins  there  is  a  profuse  and  often 
bloody  expectoration.  Inflammation  follows  more  rapidly 
the  lodgement  of  a  sharp  or  irregular  body  than  it  does  that 
of  a  round  or  smooth  body.  Inflammation  is  apt  to  produce 
edema  of  the  glottis,  bronchopneumonia,  or  ulceration  and 
necrosis  of  the  larynx.  Any  sort  of  foreign  body  in  the 
larynx  may  at  any  moment  produce  spasmodic  dyspnea,  and 
is  always  very  liable  to  cause  edema  of  the  glottis.  The 
body  if  bonv  or  metallic  can  be  detected  by  the  ;ir-rays. 

Lodgement  in  the  Trachea.— T\i&  immediate  symptoms  of 
a  foreign  body  in  the  trachea  depend  on  the  shape  and  weight 
of  the^body,'and  whether  it  becomes  fixed  in  the  mucous 
membrane  or  moves  to  and  fro  with  the  air-current.  A 
smooth,  heavy  body  falls  to  the  tracheal  bifurcation,  and,  if 

^  See  MouUin's  graphic  description  in  his  Treatise  on  Surgery. 


7l8  SURGERY  OF  THE   RESPIRATORY  ORGANS. 

it  does  not  enter  a  bronchus,  moves  with  every  breath,  and 
by  its  movement  causes  violent  laryngeal  spasm,  cough,  and 
whooping  inspiration  without  aphonia.  The  patient  is  often 
conscious  of  the  movements  of  the  foreign  body,  and  the 
surgeon  may  detect  them  with  the  stethoscope.  The  foreign 
body  may  be  found  with  the  Rontgen  rays.  A  foreign  body 
in  the  trachea  is  liable  to  cause  death  by  dyspnea,  or  it  may 
ascend  so  as  to  be  caught  in  the  larynx,  or  may  even  be 
expelled.  Irregular  or  sharp  bodies  lodge  in  the  mucous 
membrane,  produce  inflammation,  frequent  cough,  and  expec- 
toration, and  finally  lead  to  ulceration.  Bodies  which  swell 
from  heat  and  moisture  tend  to  lodge  and  to  become  fixed 
(seeds  may  sprout). 

Lodgement  in  a  Bronchus. — Foreign  bodies  in  the  bronchi 
seriously  endanger  life.  They  usually  lodge  in  the  right 
bronchus.  When  a  small  lung-area  is  obstructed  the  ob- 
structed side  shows  diminished  respiratory  movement  and 
murmur  with  occasional  whistling  sounds  and  large  moist 
rales  ;  the  percussion-note  is  normal.  When  an  entire  lobe 
is  obstructed  all  respiratory  sounds  are  absent  over  it,  and 
over  the  unobstructed  lung  respiration  is  exaggerated ;  the 
percussion-note  over  the  obstructed  area  is  at  first  resonant, 
but  becomes  dull.  The  .r-rays  will  enable  the  surgeon  to 
detect  some  foreign  bodies  in  a  bronchus.  Lodgement  in  a 
bronchus  may  cause  bronchopneumonia,  abscess,  hemor- 
rhage, and  even  gangrene.  In  some  cases  the  body  has 
been  expelled  spontaneously.  In  rare  instances  people  have 
lived  for  years  with  lodged  foreign  bodies.  If  death  does 
not  soon  follow  the  lodgement  of  a  foreign  body,  an  abscess 
is  very  apt  to  form. 

Treatment. — If  a  foreign  body  lodges  in  the  pharynx,  try 
to  pull  it  forward ;  if  this  fails,  push  it  back  into  the  esoph- 
agus. In  lodgement  in  the  larynx  or  below,  if  the  symptoms 
are  very  urgent,  at  once  perform  a  quick  laryngotomy.  If 
the  symptoms  are  not  so  urgent,  get  a  complete  history  of 
the  accident  and  find  out  the  nature  of  the  foreign  body. 
Be  sure  a  foreign  body  is  retained  in  the  respiratory  tract,  and 
determine  what  its  situation  may  be.  Often  a  laryngologist 
can  remove  a  foreign  body  from  the  larynx  by  means  of  for- 
ceps, a  mirror  and  lamp  being  used  for  illumination.  The 
fauces  and  upper  portion  of  the  larynx  should  have  cocain 
applied  to  them  to  lessen  pain  and  spasm.  If  the  surgeon  fails 
in  extraction  by  forceps,  and  laryngotomy  has  been  per- 
formed, continue  the  search  through  the  opening  in  the  crico- 
thyroid membrane ;  if  laryngotomy  has  not  been  performed, 


TRA  CUE  OTOMY.  7  1 9 

let  the  larynx  be  opened  by  tliyrotomy  (a  vertical  incision 
between  the  alae  of  the  thyroid  cartilage,  and  the  separation 
of  these  al?e  to  permit  of  exploration).  After  a  thyrotomy 
suture  the  perichondrium  with  catgut.  If  the  foreign  body  is 
in  the  trachea,  perform  ordinary  tracheotomy :  if  it  is  in  a 
bronchus,  perform  low  tracheotomy.  Tracheotomy  prevents 
suffocation  from  laryngeal  spasm  or  edema  of  the  glottis.  It 
may  be  possible  to  remove  the  body  in  the  bronchus  through 
the' incision  of  a  low  tracheotomy,  and  this  ought  to  be  tried. 
The  foreign  body  may  be  expelled  through  the  tracheotomy 
wound ;  if  it  is  not  expelled,  search  the  trachea  and  bronchi 
with  Gross's  forceps,  with  probes,  with  hooks,  or  wuth  the 
finger.  If  the  foreign  body  cannot  be  found,  put  the  patient 
to  bed,  and  maintain  a  moist  atmosphere  in  the  room.  As  a 
rule,  when  the  foreign  body  is  not  found  insert  a  tube.  If  the 
foreign  body  be  extracted,  do  not  insert  a  tube  (unless  edema 
of  the  glottis  exists  or  is  likely  to  come  on),  do  not  suture 
the  wound,  but  cover  it  with  moist  gauze  and  let  it  heal 
by  granulation.  Morphin  and  sedative  cough-mixtures  are 
given.  Gross  says  that  even  when  a  foreign  body  has  long 
been  retained  an  operation  should  be  performed  so  long 
as  the  air-passages  are  not  seriously  diseased.  What  shall 
be  done  w^hen  a  foreign  body  is  lodged  in  a  bronchus  and 
we  are  unable  to  extract  it  through  a  tracheotomy-wound  ? 
True  said  if  "the  patient  is  in  danger  of  death"  go  through 
the  chest-wall  and  attempt  to  remove  the  body.  He  said 
this  wdth  a  full  knowledge  of  the  difficulty  of  locating  the 
body.  This  difficulty  has  been  partly  overcome  by  the  ar- 
rays, and  it  seems  now  more  certainly  our  dut\^  to  operate 
than  it  was  a  short  time  ago.  Nasiloff  proposed  to  reach 
the  obstruction  by  the  posterior  route  after  rib  resection. 
Curtis  attempted  this,  and  though  the  patient  died,  his  oper- 
ation proves  that  the  method  is  feasible  and  should  be 
performed  at  once,  if  low  tracheotomy  fails. 

3.  Operations  on  the  Larynx  and  Trachea. 

Traclieotoniy. — The  instruments  required  in  this  oper- 
ation are  scalpels,  dissecting-forceps,  a  dry  dissector, 
hemostatic  forceps,  scissors,  a  tenaculum,  aneurysm-needle, 
tubes,  tapes,  Paquelin  cautery,  needles,  needle-holder,  a 
mouth-gag,  tongue-forceps,  foreign-body  forceps,  retractors, 
and,  if  membrane  is  present,  feathers  and  a  solution  of  bicar- 
bonate of  sodium.  In  a  formal  operation  give  chloroform, 
but  in  an  emergency  case  this  cannot  be  done.     The  patient 


720 


SURGERY  OF   THE   RESPIRATORY  ORGANS. 


may  be  placed  supine  with  a  sand-pillow  under  the  neck 
and  with  the  head  thrown  over  the  end  of  the  table.  If  a 
child,  Liston  used  to  wrap  it  up  to  the  neck  in  a  sheet  to 
prevent  movements  of  the  limbs,  would  seat  himself  on  a 
chair,  place  the  child  upon  the  nurse's  lap,  and  takes  its  head 
between  his  knees.  The  head  must  be  exactly  in  the  mid- 
dle line,  and  extended  (in  an  adult  this  gives  two  and  three- 
quarters  inches  of  trachea  above  the  manubrium ;  in  a 
child  of  ten,  two  and  a  quarter  inches  ;  in  a  child  of  six, 
about  two  inches).  The  operator  stands  to  the  right  side 
when  the  patient  is  supine.  If  bleeding  is  profuse  when  the 
surgeon  is  ready  to  open  the  trachea,  place  the  patient  in  the 
Trendelenburg  position  with  the  neck  extended.  The  trachea 
may  be  opened  above  or  below  the  isthmus  of  the  thyroid 
gland.  The  isthmus  in  an  adult  usually  lies  over  the 
second  and  third  rings  (Fig.  251).     The  isthmus  in  a  child 


Sfc^^^^'l      '  ^l 


Fig.  251. — Blood-supply  of  the  larynx  and 
trachea  (Esmarch  and  Kowalzig). 


Fig.  252. — Parts  exposed  in  tracheotomy 
(Esmarch  and  Kowalzig). 


usually  lies  over  the  first  ring  or  even  over  the  space  between 
the  cricoid  cartilage  and  the  first  ring.  The  high  opera- 
tion is  always  chosen  except  in  cases  where  it  is  desired 
to  search  for  a  foreign  body  in  a  bronchus. 

High  Tracheotomy. — High  tracheotomy  is  preferred 
because  in  this  region  the  muscles  are  distinctly  separated 
(Fig.  252),  the  main  vessels  of  the  neck  and  the  inferior 
thyroid  vessels  are  not  encountered,  the  anterior  jugular 
veins  are  small  and  have  very  few  transverse  branches,  and 
the  trachea  is  near  the  surface  (Treves).  The  surgeon  accu- 
rately locates  the  cricoid  and  thyroid  cartilages.     An  incision 


HIGH  TRACHEOTOMY.  "J 21 

is  begun  at  the  upper  border  of  the  cricoid  cartilage,  and  is 
carried  down  precisely  in  the  middle  line  for  about  one  and 
a  half  inches.  Treves  advises  the  operator  to  steady  the  skin 
of  the  neck  with  the  fingers  of  the  left  hand  and  to  cut  with 
the  unsupported  right  hand  (if  the  hand  be  supported,  the 
respirations  will  interfere  with  the  operation).  The  skin, 
the  superficial  fascia,  and  the  anterior  layer  of  the  ceryical 
fascia  are  incised,  the  sternohyoid  and  sternothyroid  muscles 
are  separated,  and  the  fascia  over  the  trachea  is  divided. 
This  fascia  is  attached  above  to  the  cricoid  cartilage,  and  it 
divides  below  into  two  layers  to  invest  the  thyroid  body 
and  its  isthmus.  If  veins  are  in  the  line  of  the  incision,  they 
are  pushed  aside,  but  it  is  not  necessary  to  take  the  time  to 
apply  a  double  ligature.  Even  if  bleeding  is  profuse,  as  soon 
as  the  trachea  is  opened  and  air  enters  freely  into  the  lungs 
venous  congestion  is  relieved  and  bleeding  is  apt  to  cease. 
If  hemorrhage  be  violent  and  the  veins  are  not  at  once  caught 
by  forceps,  it  may  be  well  to  place  the  patient  in  the  Tren- 
delenburg position  before  incising  the  windpipe,  in  order 
to  prevent  the  entrance  of  blood  into  the  lungs.  Before 
opening  the  trachea  the  isthmus  of  the  thyroid  gland  is 
pushed  downward  -,  if  it  cannot  be  pushed  down  sufficiently, 
a  transverse  incision  is  made  through  the  fascia  at  the  upper 
border  of  the  cricoid  cartilage,  and  the  fascia,  and  the  isthmus 
with  it,  are  lifted  off  of  the  trachea  (Bose's  method).  A 
tenaculum  is  inserted  into  the  cricoid  cartilage  in  order  to 
steady  the  tube.  The  back  of  the  knife  is  turned  toward  the 
sternum,  a  finger  being  held  upon  the  blade  to  prevent  too 
deep  a  cut  being  made.  The  knife  is  plunged,  as  if  it  were  a 
trocar,  into  the  mid-line  of  the  trachea  above  the  isthmus, 
and  two  or  three  rings  are  divided  from  below  upward.  The 
hook  is  not  removed  until  the  operation  is  completed.  If  a 
foreign  body  is  present,  an  attempt  is  made  to  remove  it ;  if 
success  attends  the  effort,  no  tube  need  be  worn  ;  but  if  the 
body  is  not  found  a  tube  must  be  used.  In  croup  or  diph- 
theria remove  membrane  (by  means  of  a  feather  and  a  solu- 
tion of  bicarbonate  of  sodium,  sij,  glycerin  .5J,  water  5x — 
Parker)  and  insert  a  tube.  The  edge  of  the  cut  is  grasped 
with  the  dissecting-forceps  the  mucous  membrane  being  in- 
cluded in  the  bite,  the  head  is  placed  erect,  the  tube  is  intro- 
duced, and  the  tenaculum  is  removed.  Secure  the  tube  by 
tapes,  and  suture  the  wound  below  the  tube.  Remove  the  tube 
at  the  first  moment  consistent  with  safety.  In  croup  or  diph- 
theria put  a  screen  around  the  bed ;  have  the  air  kept  moist 
by  steam  ;   remove  the  inner  tube  and  clean  it  ever}'  two   or 

46 


722  SURGERY  OF   THE   RESPIRATORY   ORGANS. 

three  hours  at  first ;  clean  the  outer  tube,  and  the  larynx 
and  trachea  whenever  required,  by  means  of  a  feather  and 
Parker's  solution.  A  steam  spray  atomizer  may  be  used 
with  advantage. 

Quick  laryngotomy  must  never  be  attempted  upon  a 
child  under  thirteen  years  of  age,  because  of  the  small  size 
of  the  cricothyroid  space  before  this  age  (Treves).  In 
view  of  the  difficulty  of  introducing  a  tube  and  of  wearing 
it  so  near  the  vocal  cords,  laryngotomy  should  not  be  per- 
formed for  croup,  diphtheria,  or  for  any  condition  in  which 
a  tube  must  be  long  worn.  Make  an  incision  an  inch 
and  a  quarter  long  in  the  middle  line,  from  above  the 
lower  edge  of  the  thyroid  to  below  the  lower  border  of 
the  cricoid  cartilage.  Divide  the  skin,  superficial  fascia, 
and  deep  fascia,  separate  the  cricothyroid  and  sternothy- 
roid muscles,  divide  the  deep  layer  of  fascia,  and  cut  the 
cricothyroid  membrane  horizontally  just  above  the  cricoid 
cartilage.  The  tube  must  be  shorter  than  the  tracheotomy- 
tube.  An  operation  which  opens  vertically  the  cricothyroid 
membrane,  the  cricoid  cartilage,  and  the  upper  rings  of  the 
trachea  is  called  "  laryngotracheotomy." 

Intubation  of  the  I/arynx  (O'Dwyer's  Operation). — 
Bouchot  conceived  the  idea  of  intubation  ;  O'Dwyer  perfected 
it  and  made  it  a  genuine  scientific  proceeding.  The  instru- 
ments required  for  the  performance  of  this  operation  are  a 
mouth-gag,  an  instrument  to  hold  the  tube  and  introduce 
it,  an  instrument  for  extracting  the  tube,  and  a  graduated 
scale.  The  collar  of  the  tube  has  a  perforation  through 
which  a  piece  of  silk  is  fastened  to  draw  out  the  tube.  The 
child  is  wrapped  in  a  sheet  to  secure  the  limbs,  is  seated  in 
a  nurse's  lap,  and  its  head  is  held  by  an  assistant.  The 
jaws  are  to  be  opened  and  held  apart  by  the  self-retaining 
mouth-gag.  The  surgeon  sits  in  front  of  the  patient,  wraps 
a  piece  of  rubber  plaster  about  the  index-finger  of  his  left 
hand,  and  passes  the  finger  into  the  child's  mouth  until  it 
touches  the  epiglottis.  He  introduces  the  holder  and  tube 
(observing  if  the  silk  is  free)  along  the  surface  of  the  tongue 
until  the  obturator  touches  the  epiglottis ;  raises  the  epiglot- 
tis with  the  left  index-finger,  and  passes  the  tube  into  the 
larynx ;  places  the  left  index-finger  against  the  tube,  and 
withdraws  the  holder  with  the  right  hand.  The  silken 
thread  is  tied  to  the  ear,  and  the  nurse  is  directed  to  employ 
the  thread  to  remove  the  obturator  if  it  becomes  obstructed 
or  is  coughed  up.  The  tube  is  removed  in  two  or  three 
days ;    if  breathing  is   easy,  it    is    not   reintroduced,  but  if 


PLEURITIC  EFFUSION.  723 

dyspnea  recurs,  it  is  replaced  for  two  or  three  days  more. 
If,  in  introducing  the  tube,  a  mass  of  false  membrane  is 
pushed  before  it  into  the  trachea,  breathing  ceases,  and,  if 
the  mass  is  not  at  once  coughed  up,  tracheotomy  must  be 
performed.  Wharton  feeds  these  patients  on  semisolids 
rather  than  upon  liquids  (mush,  soft  eggs,  and  corn-starch) ; 
and  if  trouble  occurs  in  swallowing  these  articles,  he  feeds 
by  the  rectum  or  by  means  of  a  tube.  In  opium-poisoning, 
in  asphyxia,  in  acute  traumatic  pneumothorax,  and  in  cere- 
bral injuries,  intubation  may  be  associated  with  the  use  of 
Fell's  apparatus  (p.  729). 

4.  Diseases    and    Injuries    of    the    Chest.  Pleur.\,  and 

LUXGS. 

Pleuritic  effusion  ma}-  arise  from  the  lodgement  of 
foreign  bodies,  from  injur}^  by  fragments  of  a  broken  rib, 
from  tumors,  and  from  inflammation  of  the  lung,  but  most 
usually  is  due  to  pleuritis.  A  common  cause  of  pleuritis  is 
tuberculosis.  Inflammatory  effusion  is  nearly  always  uni- 
lateral (except  in  tubercular  pleuritis,  but  even  this  form  is 
one-sided  in  originV 

The  signs  of  pleuritic  effusion  are — dulness  on  percussion 
over  the  effusion,  this  dulness,  when  the  patient  is  erect, 
being  at  the  lower  part  of  the  chest  and  ascending  higher 
posteriorly  than  anteriorly  (alteration  of  position  alters  the 
situation  of  the  dulness) ;  the  intercostal  spaces  are  widened 
and  the  intercostal  depressions  are  obliterated ;  no  breath- 
sounds  can  be  detected  in  the  area  of  flatness  when  the  col- 
lection of  fluid  is  large,  but  in  small  effusions  deeply  situated 
the  breath-sounds  are  often  audible ;  the  percussion-note 
above  the  Hquid  is  hyper-resonant  or  tympanitic,  and  is  often 
associated,  at  the  edge  of  the  liquid,  with  a  friction-sound ; 
posteriorly,  high  up  and  near  the  spine,  there  are  bronchial 
respiration  and  bronchophony  (J.  M.  DaCosta).  In  these 
cases  pain  disappears  with  the  advent  of  effusion,  dyspnea 
comes  on,  and  the  patient  lies  upon  the  diseased  side. 
Cough  always  exists,  and  fever  is  usually  present.  In 
serous  effusions  the  diagnosis  may  be  confirmed  by  the 
introduction  of  an  asepticized  aspirating-needle. 

The  treatment  in  this  stage  is  to  discontinue  arterial  seda- 
tives and  to  stimulate  if  the  circulation  calls  for  it.  The 
exudation  is  removed  by  the  administration  of  salines,  com- 
pound jalap  powder,  or  elaterium.  If  these  means  fail,  if 
the  effusion  is  excessive,  or  if  it  is  producing  dyspnea,  at 


724         SURGERY  OF   THE   RESPIRATORY  ORGANS. 

once  aspirate.  Aspiration  should  be  performed  for  an  effu- 
sion which  fills  the  whole  chest,  which  produces  great  dysp- 
nea, or  which  has  lasted  for  three  weeks.  In  tubercular 
pleuritis  early  aspiration  is  not  advisable,  but  aspiration 
should  be  performed  if  the  fluid  becomes  purulent,  if  the 
effusion  displaces  the  lieart  considerably,  and  if  it  adds 
notably  to  the  dyspnea.  If  pus  forms,  the  proper  proced- 
ure is  incision,  resection  of  a  rib,  and  drainage. 

Empyema  is  a  collection  of  pus  in  the  pleural  cavity.  It 
may  begin  suddenly,  but  rarely  does  so.  Among  the  causes 
of  empyema  are  those  of  serous  effusion.  Empyema  is  due 
to  infection  of  the  pleura,  and  in  every  case  a  bacteriological 
study  should  be  made  of  the  pus  to  discover  the  causative 
organism.  The  pneumococcus  is  the  causative  organism 
in  many  of  the  cases  which  follow  pneumonia.  This 
organism  lives  but  a  short  time,  and  in  empyema  due  to 
pneumococci  these  organisms  may  not  be  discoverable  when 
the  pus  is  evacuated.  In  most  cases  of  empyema  strepto^ 
cocci  or  staphylococci  can  be  found  in  the  pus.  These 
organisms  may  appear  in  an  empyema  induced  originally 
by  pneumococci  (Stephen  Paget).  In  empyema  developing 
during  or  after  typhoid  fever  the  typhoid  bacillus  may  be 
discovered.  In  putrid  empyema  various  bacteria  are  found. 
Bouchard  thinks  acute  empyema  has  a  special  organism.  The 
bacilli  of  tuberculosis  are  present  in  tubercular  empyema,  but 
may  disappear  after  mixed  infection  with  pyogenic  bacteria. 
Empyema  may  be  due  to  a  wound  or  contusion,  an  attack 
of  pneumonia,  tubercular  pleuritis,  phthisis,  influenza,  infec- 
tion of  a  serous  effusion,  caries  of  a  rib,  specific  fevers, 
especially  typhoid,  peritonitis,  abscess  of  the  liver,  suppurat- 
ing hydatid  cyst  of  the  liver,  subphrenic  abscess,  malignant 
disease  of  the  pleura,  gangrene  of  the  lung,  and  pneumothorax. 
The  signs  are  in  reality  those  of  pleuritis  with  effusion,  viz., 
dulness  on  percussion,  absent  breath-sounds  over  the  puru- 
lent matter,  bulging  of  the  intercostal  spaces,  and  sometimes 
edema  of  the  skin  of  the  chest.  The  symptoms  of  acute 
empyema  are  dyspnea,  pallor,  cough,  sweats,  chills,  and  usu- 
ally irregular  fever,  but  fever  may  be  absent.  There  is 
marked  leukocytosis.  The  fingers  may  become  clubbed. 
An  empyema  of  the  left  side  may  pulsate.  A  neglected 
empyema  may  break  into  the  lung,  esophagus,  or  peri- 
cardium, through  an  intercostal  space,  or  may  point  in  the 
lumbar  region.  When  an  empyema  is  pointing  externally, 
the  condition  is  called  empyema  necessitatus.  After  an 
empyema   ruptures    spontaneously  it   rarely  heals    without 


EMPYEMA.  725 

surgical  interference,  a  fistula,  as  a  rule,  persisting.  When 
an  empyema  ruptures  into  a  bronchus,  pneumothorax  arises 
as  a  rule.  Empyema  may  cause  death  by  compression  of 
the  heart  and  lung,  pulmonary  embolism,  pericarditis,  peri- 
tonitis, cerebral  embolism,  cerebral  abscess,  septicemia  (Ste- 
phen Paget),  exhaustion,  or  rupture  into  a  bronchus. 

A  small  empyema  due  to  pneumococci  occasionally, 
though  very  rarely,  undergoes  spontaneous  cure,  the  pus 
being  absorbed  (Stephen  Paget). 

A  small  empyema  is  occasionally  cured  by  encapsulation 
with  fibrous  tissue. 

Under  exceptional  circumstances,  even  a  large  empyema 
may  be  cured  by  breaking  externally  or  into  a  bronchus.  A 
subphrenic  abscess  may  follow  an  empyema. 

Empyema  is  so  rarely  cured  spontaneously  that  it  does 
not  do  to  trust  to  Nature,  and  practically  almost  every  case 
will  die  without  surgical  treatment. 

Double  empyema  is  a  rare  and  extremely  fatal  condition. 
There  are  two  forms  of  empyema,  the  acute,  which  comes 
on  as  a  violent  inflammation,  and  the  chronic. 

Chronic  empyema  may  follow  an  acute  empyema,  or  the 
condition  may  be  chronic  from  the  beginning.  In  chronic 
empyema  the  lung  is  compressed,  shrunken,  and  strongly 
adherent,  and  the  pleura  is  very  thick.  In  some  cases  the 
pleura  is  over  an  inch  thick.  This  thickening  is  brought 
about  by  the  deposition  of  layer  after  layer  of  fibrin.  In  not 
a  few  cases  a  chronic  empyema  succeeds  an  acute  one  or  is 
itself  maintained  because  a  drainage-tube  has  slipped  into 
the  pleural  cavity  and  remains  lodged. 

A  closed  empyema  is  one  in  which  no  opening  has  been 
made  by  the  surgeon  and  no  opening  has  formed  sponta- 
neously. In  a  closed  empyema  the  pus  is  rarely  putrid; 
in  an  open  empyema  the  pus  is  often  putrid. 

Treatment  of  Empyema. — The  treatment  is  purely  sur- 
gical, and  the  earlier  it  is  applied  the  better.  To  delay  allows 
the  pleura  to  thicken  and  permits  adhesions  to  form,  con- 
ditions which  prevent  lung  expansion  and  retard  or  even 
prevent  cure.  The  results  of  operation  are  better  in  children 
than  in  adults ;  in  small  collections  than  in  large ;  in  recent 
than  in  advanced  cases ;  in  pneumococcus  empyema  than  in 
empyema  due  to  other  organisms.  The  surgical  treatment 
comprises  aspiration,  incision,  rib-resection,  the  operation  of 
Schede,  and  the  operation  of  Estlander  (see  p.  738). 

In  acute  empyema  general  practitioners  are  veiy  apt  to 
aspirate,  and  yet  aspiration  is  almost  nev^er  curative.     It  may 


726  SUHGERY  OF  THE  RESPIRATORY  ORGANS. 

cure  a  pneumococcus  empyema  in  a  child,  and  an  encysted 
empyema,  but  even  in  these  it  will  usually  fail.  Aspiration 
is  not  to  be  considered  a  method  of  curative  treatment.  It 
is  to  be  regarded  as  the  surgical  treatment  only  in  a  tuber- 
cular empyema  in  a  young  person  with  rapidly  progressing 
phthisis,  because  in  such  a  case  incision  will  prove  fatal 
(Lockwood).  It  is  a  very  useful  diagnostic  expedient,  and 
enables  the  surgeon  to  prove  the  existence  of  pus,  and  the 
pus  which  is  obtained  can  be  examined  bacteriologically.  In 
a  very  large  effusion  it  is  wise  to  aspirate  and  withdraw  part 
of  the  effusion  a  day  or  two  before  operating.  This  enables 
the  patient  to  take  an  anesthetic  with  greater  safety  and 
obviates  the  danger  attending  the  rapid  evacuation  of  a  large 
amount  of  pus. 

In  a  recent  empyema  incision  and  drainage  or  rib  resection 
and  drainage  will  often  cure  the  case,  and  yet  many  of  the 
results  are  unsatisfactory.  In  some  cases  the  discharge  ceases^ 
and  yet  pulmonary  function  is  not  completely  restored.  Tn 
other  cases  a  pleural  fistula  persists.  If  a  profuse  discharge 
is  maintained,  amyloid  disease  may  arise.  An  acute  empy- 
ema is  to  be  drained  by  intercostal  incision  or  by  resection 
of  a  rib.  A  chronic  closed  empyema  is  drained  in  the  same 
manner,  and  if  the  lung  will  not  fully  expand  and  remains 
stationary  for  a  month  Schede's  or  Estlander's  operation  is 
required.  An  open  chronic  empyema,  in  which  the  lung 
will  not  expand,  requires  the  operation  of  Schede  or  Est- 
lander.  When  there  is  an  external  opening  which  persists, 
and  which  joins  a  long,  narrow  cavity,  the  condition  is 
spoken  of  as  pleural  fistula,  and  pleural  fistula  is  often  pro- 
duced by  the  prolonged  use  of  a  drainage-tube  and  some- 
times by  caries  of  a  rib.  A  pleural  fistula  may  sometimes 
be  cured  by  dilatation  of  the  sinus,  but  in  most  cases  it  is 
necessary  to  resect  one  or  more  ribs.  Even  if  there  is  no 
opening  on  the  cutaneous  surface,  there  may  be  one  into 
a  bronchus.  In  total  empyema  the  entire  sac  of  the  pleura 
is  involved ;  in  partial  or  localized  empyema  the  purulent 
matter  is  encapsuled. 

Non-traumatic  Pneumotliorax. — By  the  term  pneumo- 
thorax is  meant  the  presence  of  air  in  the  pleural  cavity.  As  a 
rule,  besides  air  there  is  serous  fluid  or  pus.  It  may  be  due  to 
the  rupture  of  an  empyema  into  a  bronchus  ;  to  the  rupture  of 
a  tubercular  area,  an  area  of  gangrene,  an  abscess  of  the  lung, 
an  air-cell  in  a  state  of  emphysema,  or  of  pulmonary  tissue 
softened  because  of  hemorrhagic  infarction.  The  immediate 
effect  of  the  entrance  of  air  into  the  pleural  sac  is  to  compress 


NON-TRAUMATIC  PNEUMOTHORAX.  7V 

the  luno-  the  degree  of  compression  being  in  proportion  to 
the  amount  of  gas  present.  In  severe  cases  the  lung  is 
squeezed  against  the  vertebral  column,  and  the  heart,  the 
diaphrao-m  and  even  the  liver  are  displaced.  In  some  cases, 
where  tlie  admission  of  air  does  not  continue,  the  amount 
already  in  the  pleural  sac  is  absorbed.  In  most  cases  pyo- 
pneumothorax (empyema)  follows. 

Symptoms.— The  svmptoms  usually  arise  suddenly,  and 
consist  of  distressing  dyspnea,  pain  in  the  chest,  lividity,  and 
rapiditv  and  weakness  of  the  pulse.  In  some  cases  of 
phthisis  the  svmptoms  are  not  very  severe.  It  has  been 
pointed  out  that  occasionally  in  phthisis  pneumothorax 
seems  to  actually  benefit  the  tubercular  area  in  the  lung. 
The  phvsical  signs  of  pneumothorax  are  as  fo  lows:  the 
affected'side  of  the  chest  is  bulged  and  immobile,  and  the 
heart  is  displaced,  especially  if  the  condition  affects  the  lett 
side.  Palpation  discovers  that  vocal  fremitus  is  lessened  or 
absent  The  percussion-note  is  t>mipanitic.  In  some  rare 
cases  the  percussion-note  is  dull.  When  fluid  gathers  there 
is  a  positively  dull  note  on  percussion  over  the  fluid.  On 
auscultation  it  is  found  that  the  breath-sounds  are  very 
feeble  or  absent.  The  voice  is  transmitted  as  a  metallic 
sound,  the  rales  sound  metallic,  and  on  coughing  there  may 
be  metallic  tinkling. 

Treatment.— Osier  says  the  treatment  should  be  the  same 
as  that  of  pleurisy  with  effusion.  In  many  cases  it  is  wise  to 
aspirate  and  remove  air  and  serous  effusion.  If  pus  forms,  a 
rib  should  be  resected  and  a  tube  inserted  (see  Empyema). 
In  pneumothorax  occurring  during  chronic  phthisis  oper- 
ation is  of  great  service.  In  cases  with  rapidly  progressive 
phthisis  it  is  practically  useless. 

If  there  is  an  opening  in  a  bronchus,  aspiration  will  not 
get  rid  of  air  ;  the  air  will  enter  into  the  pleura  as  rapidly 
as  the  aspirator  removes  it.  Incision  has  dangers  of  its 
own  :  the  diaphragm  is  flapping  during  respiration  and  may 
be  injured  (Fowler),  and  when  the  pleura  is  opened  there  is 
a  great  alteration  produced  in  the  air-pressure  in  the  chest, 
and  the  patient  may  "drown  in  his  own  secretions."  After 
incision  irrigation  'is  not  justifiable,  because  the  fluid  may 
enter  a  bronchus  and  produce  suffocation  (Fowler). 

West's    rule    is  a   good    one^ — that    is,   early    incision   is 

dangerous.     In    an    early    stage    use    paracentesis    without 

suctton.     This  will  often  relieve  the  patient.     If  paracentesis 

does  relieve  him,  wait  awhile  and  perhaps  repeat  the  oper- 

1  Brit.  Med.  Jour.,  November  27,  1897. 


728  SURGERY  OF   THE  RESPIRATORY  ORGANS. 

ation  if  the  symptoms  again  became  severe.  If  paracentesis 
does  relieve,  incise,  resect  a  portion  of  a  rib,  and  drain.  If 
pus  forms,  an  incision  must  be  made  and  a  portion  of  a  rib 
resected,  to  afford  exit  to  the  fluid. 

Fowler  points  out  that  if  the  lung  is  bound  down  by- 
adhesions,  incision  is  dangerous  but  justifiable.  Operation 
at  the  proper  time  often  prevents  the  lung  being  bound  down 
by  adhesions. 

Acute  Traumatic  Pneumothorax. — This  is  produced 
by  the  sudden  admission  of  a  quantity  of  air  into  the  pleural 
cavity  as  a  result  of  a  wound  of  the  chest-wall.  A  small 
quantity  of  air,  or  the  gradual  introduction  of  considerable 
air  does  not,  as  a  rule,  produce  very  serious  symptoms.  The 
sudden  admission  of  a  quantity  of  air  causes  very  dangerous 
symptoms,  and  even  death.  A  quantity  of  air  may  be  ad- 
mitted rather  suddenly  as  a  result  of  an  accident  or  during 
the  performance  of  a  surgical  operation  which  opens  the 
pleura.  It  sometimes  arises  during  the  removal  of  tumors 
from  the  chest-wall,  during  operations  upon  the  lung,  and 
during  empyema  operations.  As  a  rule,  when  pulmonary 
adhesions  exist,  dangerous  symptoms  do  not  arise,  even 
when  the  pleura  is  widely  opened,  and  adhesions  exist  in 
25  per  cent,  of  empyema  cases  seen  by  the  surgeon.^ 

It  used  to  be  taught  that  whenever  the  pleura  is  opened 
there  is  a  strong  tendency  to  the  development  of  pneumo- 
thorax, but  West  has  shown  that  the  surfaces  of  the  pleura 
often  cohere  with  a  force  superior  to  pulmonary  elasticity, 
and  in  such  cases  pneumothorax  does  not  arise. 

Symptoms. — When  the  pleura  is  opened  during  an 
operation  or  by  an  injury,  the  symptoms  may  be  trivial  and 
transitory,  may  be  tolerably  severe,  may  be  extremely  grave, 
and  the  patient  may  quickly  die  (Quenu  and  Longuetj. 
Rudolph  Matas  sets  forth  the  symptoms  as  presented  by 
the  French  observers:^ 

The  mild  symptoms  are  a  weak,  slow  pulse  and  irregu- 
lar, noisy  respiration. 

The  severe  symptoms  are  slow  pulse,  slow  and  irregular 
respiration,  and  dyspnea,  continuing  after  the  anesthetic  has 
been  withdrawn. 

The  grave  symptoms  are  cyanosis  ;  collapse  ;  small,  weak 
pulse ;  shallow  and  noisy  respiration  ;  and  spells  of  syncope. 
Death  may  occur  suddenly  from  inhibition,  or  later  from 
mechanical  asphyxia  (Matas). 

'  Rudolph  Matas,  Annals  of  Surgery,  April,  1899. 
'  Annals  of  Surgery,  April,  1899. 


COXTL'SIOXS  AXD    IVOL'XDS    OF   THE    CHEST.         729 


Treatment.— Wirious  plans  have  been  adopted  :  suturing 
the  opening  in  the  pleura ;  plugging  the  opening  ;  pulling 
the  diaphragm  into  the  wound  in  the  chest-wall  and  suturing 
it;  and  grasping  the  lung  and  suturing  it  to  the  wound. 
Whenever  the  pleura  is  wideh'  opened,  follow  the  advice  of 
Matas  and  use  the  Fell-0'Dwyer  apparatus,  and  when  the 
operation  is  completed,  suture  the  lung  to  the  margin  of  the 
opening  in  the  pleura  with  a  continuous  catgut  suture.  Par- 
ham  has  followed  this  plan  and  the  lung  w^as  kept  from  col- 
lapsing.^ 

The  Fell-O'Dwyer  ap- 
paratus   is    shown    in    Fig. 

253- 

O'Dwyer's  tube  is  intro- 
duced into  the  glottis  and 
is  attached  to  a  bellows,  the 
lung  is  inflated,  respiration 
is  maintained  by  the  use  of 
the  bellows,  and  collapse 
with  all  its  dangers  is 
avoided. 

Contusions  and 
Wounds  of  the  Chest. 
— Contusions. — A  contus- 
ion may  be  trivial  and  lim- 
ited to  the  superficial  parts 
of  the  chest-wall;  it  may 
involve  the  muscles  ;  it  may 
be  associated  with  fracture 
of  the  ribs  or  sternum  or 
wdth  visceral  injury. 

Symptoms. — In  an  or- 
dinar}-  contusion  without 
visceral    injurs^    there    are 

considerable   pain,   discolor-  pj^      253.— The      Fell-O'Dwyer    apparatus. 

ation,  and  often  much  swell-     ™^  ,t ^1lL°."s  t^^^ bTennS^el' b," th^ 
ing.     The  patient  prefers  to  -  f^'^^t^-,'^;,^,-rp?oTrdl^':.ifhTro:g^ 

lie    UDOn    the    back     and  the        acts  as  a'powerfol  foot-piece  for  compressm|^the 
y      .  .  11-1  machine  with  the  least  amount  of  muscular  eflort. 

respiration     is     abdominal. 

After  a  severe  blow   upon 

the  chest  there  is  great  shock  and  may  even  be  instant  death. 

The  condition  of  shock  so  produced  is  called  concussion  of 

1  F  W  Parham's  paper  on  "  Thoracic  Resection  for  Tumors  Growing  from 
the  Bony  Walls  of  the  Chest."  Read  before  the  Southern  Surgical  and  Gyneco- 
logical Association,  November,  1898. 


730  SURGERY  OF  THE   RESPIRATORY  ORGANS. 

the  chest.  Broken  ribs  may  injure  the  pleura  or  lung.  After 
a  severe  blow  upon  the  chest  a  limited  area  of  inflammation 
may  arise  in  the  pleura  (traumatic  pleuritis).  Severe  visceral 
injury  is  announced  by  positive  symptoms.  A  contusion  of 
the  hing  causes  pain,  cough,  expectoration  of  bloody  mucus, 
dyspnea,  and  possibly  distinct  hemoptysis.  Over  the  con- 
tused region  the  percussion-note  is  dull  and  on  auscultation 
crepitus  is  audible.  A  limited  pneumonia  follows,  but  genu- 
ine croupous  pneumonia  may  arise. 

In  rupture  of  the  lung-,  besides  the  symptoms  above 
noted,  there  are  hemothorax  and  pneumothorax. 

Rupture  of  the  diaphrag-m  causes  pain  and  dyspnea,  and 
often  vomiting.  The  stomach  or  intestine  may  pass  into 
the  pleural  sac.  If  this  happens,  there  will  be  a  tympanitic 
percussion-note  over  the  displaced  viscus  and  symptoms  will 
vary  with  the  viscus  involved.  In  a  case  in  the  Jefferson 
Medical  College  Hospital,  in  which  the  stomach  passed  into 
the  left  pleural  sac,  there  were  persistent  vomiting,  violent 
pain  in  the  chest,  and  displacement  of  the  apex-beat.  Such 
a  diaphragmatic  hernia  may  become  strangulated. 

Treatment  of  Contusions  of  the  Chest, — An  ordinary 
contusion  is  treated  as  directed  in  the  section  on  Contusions 
(p.  204),  and  the  chest  is  strapped  with  adhesive  plaster,  as 
in  the  treatment  of  fractured  ribs.  In  concussion  of  the 
chest  the  treatment  for  shock  is  applied.  It  may  be  neces- 
sary to  employ  artificial  respiration  for  a  time.  If  a  dia- 
phragmatic hernia  is  diagnosticated,  the  abdomen  should  be 
opened,  the  displaced  viscera  restored  to  their  proper  abode, 
and  the  diaphragm  sutured.  The  diaphragm  may  also  be 
reached  by  resecting  several  ribs  and  opening  the  pleural 
sac.  In  contusions  of  the  lung  cold  is  applied  to  the  chest, 
and  any  inflammation  which  arises  is  treated  according  to 
general  rules.  In  rupture  of  the  lung  the  case  may  be  treated 
expectantly,  but  dangerous  and  continued  bleeding  or  pneu- 
mothorax may  render  surgical  interference  necessary. 

Wounds  of  the  Chest. — Non-penetrating  wounds  are  not 
particularly  grave,  and  are  treated  according  to  general 
principles,  the  chest  being  immobilized.  Penetrating  wounds 
are  extremely  grave,  as  viscera  are  apt  to  be  injured.  In 
such  a  wound  an  intercostal  artery  may  be  severed  or  the 
internal  mammary  artery  may  be  divided.  An  intercostal 
artery  is  rarely  divided  unless  a  rib  is  broken.  The  surgeon 
should  always  examine  carefully  in  order  to  determine 
whether  an  intercostal  artery  or  the  internal  mammary 
artery   has   been   divided,  and,  in  doing  so,   should  bear  in 


COXTC'S/OXS  AXD    IVOLXDS   OF   THE    CHEST.         73 1 

mind  the  admonition  of  Matas,  that  is,  the  bleeding  from 
one  of  these  vessels  may  be  internal,  the  blood  collecting  in 
the  pleural  sac.  The  pericardium  or  heart  may  be  injured 
(p.  303).  A  wound  of  the  pleura  is  usually,  but  not  always, 
associated  with  a  wound  of  the  lung.  If  the  lung  is  in- 
jured, there  are  usually  great  shock,  pain  in  the  chest,  dysp- 
nea, and  cough.  In  a  large  wound  damage  to  the  lung  will 
be  indicated  if  air  is  sucked  into  the  wound  during  inspira- 
tion and  expelled  during  expiration,  and  blood  is  forced 
out  of  the  wound  by  coughing.  The  lung  may  be  visible 
or  may  protrude  (hernia  of  the  lung).  In  a  small  wound  it 
is  often  difficult  and  sometimes  impossible  to  determine 
whether  the  lung  has  been  injured.  Pneumothorax  with 
pulmonary  collapse  proves  it  has.  Severe  hemothorax 
strongly  suggests  it.  Spitting  blood  does  not  prove  it. 
In  some  severe  cases  there  is  no  hemoptysis ;  in  some 
slight  bruises  the  amount  of  blood  coughed  up  is  large. 
Emphysema  about  the  wound  does  not  prove  lung  injury. 
An  incised  wound  of  the  lung  is  apt  to  produce  rapid  death 
from  hemorrhage,  especially  if  the  wound  is  at  the  root  of 
the  lung.  A  pistol-bullet  or  a  sporting-rifle  bullet  is  not 
usually  productive  of  great  primary  hemorrhage  ;  but  infec- 
tion usually  follows,  and  secondary  hemorrhage  is  apt  to 
occur.  The  modern  military-rifle  ball  passes  through,  rarely 
lodges,  is  aseptic,  and  often  produces  astonishingly  little 
trouble.  A  pistol-bullet  and  an  old-time  rifle  bullet  may 
lodge  or  may  perforate. 

Treatment. — Bring  about  reaction  as  pointed  out  on  page 
207. 

In  an  incised  wound,  if  the  wound  is  large,  carefully 
inspect  it.  If  the  wound  is  small,  cut  down  layer  by  layer 
until  the  depths  of  the  wound  are  reached.  Disinfect  the 
wound  and  arrest  hemorrhage.  If  the  pleura  is  not  open, 
proceed  according  to  general  rules  (p.  209).  If  the  pleura 
is  found  to  have  been  opened,  suture  it  with  catgut,  close 
the  superficial  wound,  dress  with  gauze,  and  immobilize 
the  chest-wall. 

The  above  proceedings  should  be  carried  out  whether  it 
is  or  is  not  believed  that  the  lung  has  been  damaged,  pro- 
vided there  is  no  pneumothorax  and  no  violent  hemorrhage. 
What  course  shall  be  pursued  if  the  lung  has  been  injured 
by  a  stab  ?  If  hemorrhage  does  not  threaten  life  and  there  is 
no  pneumothorax,  the  patient  is  kept  at  rest  and  observed. 
If  pneumothorax  occurs,  the -pleural  sac  must  be  drained  by 
means  of  a  tube,  because  clots  must  be  evacuated  and  infec- 


732  SURGERY  OF   THE   RESPIRATORY  ORGANS. 

tion  should  be  anticipated.  If  hemorrhage  into  the  pleural 
sac  persists,  active  measures  become  necessary.  The  use  of 
ice-bags  and  drugs  is  but  waste  of  time.  Some  surgeons 
believe  that  the  mere  closure  of  the  external  wound  leads 
to  arrest  of  hemorrhage,  blood  accumulating  and  making 
pressure.  It  is  true  that  hemorrhage  often  ceases  after 
suturing  or  plugging  a  wound  and  strapping  the  chest,  but 
it  is  not  probable  that  it  ceases  because  of  these  measures. 
Blood  in  the  pleura  will  not  clot  for  many  days.  Further, 
as  Le  Conte  shows,  as  the  blood  is  forced  against  the  root 
of  the  lung,  the  right  heart  is  engorged,  the  blood-pressure 
is  raised,  and  the  bleeding  continues.^ 

Bleeding  from  the  lung  can  often  be  arrested  by  inserting 
the  end  of  a  drainage-tube  into  the  pleural  sac.  In  cases 
where  a  drainage-tube  is  inserted  into  the  pleural  cavity  and 
free  drainage  established,  the  pleura  is  immediately  filled 
with  air,  and  the  muscles  of  respiration  are  kept  from- 
acting  on  the  lung.  The  lung  contracts  by  its  own  elastic 
tissue,  as  well  as  by  the  pressure  exerted  by  the  pneumo- 
thorax, and  at  the  same  time  the  presence  of  the  air  favors 
clotting  in  the  severed  vessels.^  If  the  insertion  of  a  tube 
fails,  or  if  the  bleeding  is  rapid  and  obviously  seriously 
threatens  life,  several  ribs  must  be  rapidly  resected  and  the 
bleeding  part  explored.  In  some  cases  the  bleeding  may 
be  arrested  by  ligation,  in  some  cases  by  packing  a  small 
wound  with  gauze,  in  some  cases  by  the  suture  ligature.  In 
a  violent  secondary  hemorrhage  following  a  gunshot-wound 
of  the  lung  the  author  packed  the  entire  pleural  cavity  with 
sterile  gauze  to  obtain  a  base  of  support,  and  arrested  the 
bleeding  by  carrying  iodoform  gauze  directly  against  the 
oozing  surface.^  After  arresting  hemorrhage  in  hemothorax, 
turn  out  the  clots  and  employ  drainage.  In  a  perforating 
wound  inflicted  by  a  bullet,  reaction  must  be  brought  about, 
the  wound  should  be  dressed  antiseptically,  the  chest  should  be 
strapped,  and  the  patient  kept  quiet.  If  pneumothorax  occurs, 
the  pleura  should  be  drained  with  a  tube.  If  hemorrhage 
occurs,  it  should  be  met  as  directed  above.  In  a  wound  in 
which  the  bullet  has  lodged  an  examination  should  be  made 
to  see  if  the  bullet  is  under  the  skin  and  if  it  is,  it  is  removed 
after  the  patient  has  reacted.  It  should  always  be  borne  in 
mind  that  a  pistol-bullet  may  be  deflected  by  a  rib  or  may 
pass  from  the  front  to  the  back  part  of  the  chest  by  making 

'  Attnah  of  Surgery,  April,  1 899. 

^  Le  Conte,  in  Annals  of  Surgery,  April,  1 899. 

*  Annals  of  Surgery,  Jan.,  1898. 


TUBERCULAR    CAVITY  IX  THE   LUXG.  733 

a  burrow  under  the  skin  (^a  contour  wound).  If  a  bullet  is 
lodged,  no  attempt  should  be  made  to  remove  it  unless  an 
operation  must  be  done  for  bleeding,  unless  the  bullet  causes 
trouble,  or  unless  it  is  felt  under  the  skin.  Under  no  cn-- 
cumstances  conduct  a  long  search  for  a  bullet.  If  emphy- 
sema of  the  chest-walls  is  moderate,  strapping  or  a  bandage 
will  control  it;  if  it  is  great,  make  multiple  punctures  and 
then  apply  pressure.  In  hernia  of  the  lung  try  to  restore 
the  protrusion  ;  but  if  restoration  is  impossible  or  if  gan- 
grene seems  highly  probable,  ligate  the  base  of  the  pro- 
trusion with  silk  and  cut  away  the  mass. 

Abscess  of  the  lung  may  follow  ordinary  pneumonia. 
It  is  apt  to  follow  aspiration-pneumonia.  Osier  tells  us  that  it 
may  be  caused  by  the  aspiration  of  septic  particles  after 
"  wounds  of  the  neck,  operations  upon  the  throat,"  and  sup- 
purative lesions  of  the  nose,  larynx,  or  ear.  Cancer  of  the 
esophagus  may  be  a  cause,  so  ma}-  perforation  of  the  lung 
by  an  abscess,  wound  of  the  lung,  impaction  of  a  foreign 
body  in  the  lung,  suppuration  about  a  focus  of  tubercle  or 
metastatic  abscess.^ 

Symptoms.— The  physical  signs  of  a  large  cavity  are 
found,  and  there  is  profuse  and  extensive  expectoration, 
the  expectorated  matter  containing  portions  of  lung-tissue. 
Pyemic  abscesses  are  hard  to  diagnosticate. 

'  The  treatment  is  purely  surgical  (pneumotomy).  Make 
an  incision  over  the  cavity.  Resect  a  portion  of  one  or  more 
ribs.  Expose  the  pleura.  If  the  two  layers  of  the  pleura 
are  not  adherent,  suture  them  together  and  wait  two  days. 
If  thev  are  adherent,  proceed  at  once.  Search  for  the  ab- 
scess with  an  aspirator  needle.  When  the  cavity  is  found, 
open  into  it  with  the  cauteiy  and  insert  a  drainage-tube. 

Gangrene  of  the  I^ung.— This  term  means  the  putre- 
faction oi  a  devitalized  portion  of  pulmonar)^  tissue.  It  may 
follow  pneumonia,  or  may  be  due  to  diabetes,  to  embolism  of 
the  pulmonary  arter}%  bronchiectasis,  tuberculosis,  or  malig- 
nant disease. 

Symptoms. — The  s}-mptoms  of  a  cavity  exist ;  horribly 
offensive  sputum,  which  contains  fragments  of  lung-tissue 
and  often  altered  blood,  is  expectorated  ;  there  are  some  fever 
and  great  exhaustion.  The  fetor  of  the  discharge  is  charac- 
teristic, and  is  much  more  intense  than  the  fetor  of  abscess. 
The  treatment  is  to  operate  as  for  pulmonaiy  abscess. 
Tubercular  Cavity  in  the  I/Ung.— Surg-ical  Treat- 
Hient.— For    the    past    decade    surgical    thought    has    been 

1  See  Osier's  Practice  of  Medicine. 


734  SCRGERY  OF  THE   RESPIRATORY  ORGANS. 

actively  directed  toward  placing  on  a  scientific  footing  op- 
erations for  pulmonary  phthisis.  The  matter  is  still  in  a 
transition-stage,  and  operations  at  present  have  but  a  very 
hmited  field  of  application,  although  Sonnenberg  and  others 
have  reported  cures.  Mosler,  a  number  of  years  ago,  at- 
tempted to  treat  cavities  by  introducing  a  trocar  into  the 
cavity  and  injectmg  permanganate  of  potassium  solution 
through  the  cannula.  Patients  were  not  benefited  by  this 
procedure.  Hillier  tried  injection  of  corrosive  subhmate 
into  the  lung-parenchyma,  but  the  effect  of  the  injections  was 
disastrous.  When  the  strength  of  the  patient  is  well  pre- 
served and  the  pulmonary  lesion  is  circumscribed  and  slowly 
progressive  it  may  be  justifiable  to  perform  an  operation, 
open  the  cavity,  and  treat  it  directly  (pneumotomy).  Fowler 
says  it  is  not  justifiable  to  operate  if  the  disease  has  come 
"  to  a  standstill."  The  same  surgeon  states  that  the  only  ac- 
cessible region  is  bounded  above  by  the  clavicle,  to  the  inner 
side  by  the  manubrium,  to  the  outer  side  by  the  lesser  pec- 
toral muscle,  and  below  by  the  second  rib.^ 

Mauclaise  says  that  pneumotomy  is  only  justifiable  in  cir- 
cumscribed tubercular  cavities  without  peripheral  infiltra- 
tion and  in  pulmonary  abscesses.^  Bronchiectatic  cavities  are 
usually  multiple  ;  they  are  excessively  difficult  to  locate,  and 
treatment  by  pneumotomy  should  not  be  attempted.  In  the 
treatment  of  pulmonary  tuberculosis  resection  of  the  diseased 
area  has  been  proposed  (pneumectomy).  Tuffier  successfully 
performed  this  operation.  Surgeons,  as  a  rule,  do  not  believe 
in  pneumectomy.  Reclus  voices  the  general  opinion  when 
he  says  the  operation  is  not  required  if  the  area  of  disease  is 
very  limited,  as  such  a  condition  is  frequently  curable  by 
medical  means,  and  it  does  no  good  if  the  area  of  disease  is 
extensive.'* 

It  has  long  been  known  that  pneumothorax  might  benefit 
a  tubercular  lung.  Attempts  have  been  made  by  Farlanini 
and  Murphy  to  cure  phthisis  by  the  deliberate  production  of 
pneumothorax.  Murphy  injects  nitrogen  gas  into  the  pleural 
sac,  and  believes  that  the  method  is  of  great  value. 

It  has  been  suggested  that  in  extensive  unilateral  tubercu- 
losis of  the  lung  resection  of  a  number  of  ribs  will  favor  cure 
by  permitting  retraction  of  the  chest-wall.^ 

^  See   the   very   full  and  thoupjhtful  article  of    George   Ryerson    Fowler   on 
"  The  Surgery  of  Intrathoracic  Tuberculosis,"   Annals  of  Surgety,  Nov.,  1896. 
2  La  Tribune  ?ni(iicale,  Sept.,  21,  1S93. 

*  Revue  de  Chirurgie,  Nov.  11,  1895. 

*  Allis,  to  State  Med.  Soc.  of  Penn.  in  1S91. 


PAKACEXTESIS    THORACIS.  735 

Operation's  on  Pleura  and  Lung. 

Exploratory  Puncture  of  tlie  Pleural  Sac. — Punct- 
ure often  gi\-es  valuable  information  as  to  the  existence  of 
fluid  in  the  pleural  sac  and  as  to  the  nature  of  the  fluid. 
The  operation  must  be  performed  with  aseptic  care,  other- 
wise a  serous  eftusion  might  be  converted  into  a  purulent 
effusion,  and  either  a  serous  or  a  purulent  effusion  might 
be  rendered  putrid.  A  large  hypodermatic  syringe  with  a 
long  and  strong  needle  is  used  for  exploratory  puncture.  A 
slender  needle  breaks  easily,  and  is  unsafe.  In  order  to 
prevent  breaking  of  the  needle  impress  upon  the  patient  the 
absolute  necessity  of  keeping  quiet  and  avoiding  any  vio- 
lent respiratoiy  or  general  movement  during  the  operation. 
It  is  not  desirable  to  stick  the  lung,  although  harm  rarely 
results  from  such  an  accident.  If  no  fluid  is  found  in  the 
pleura  on  one  trial,  several  other  punctures  should  be  made. 
What  is  known  as  a  dry  tap  may  be  due  to  the  entire  absence 
of  fluid,  to  encapsulation  of  fluid  in  a  region  not  invaded  by  the 
needle,  to  the  lodgement  of  the  point  of  the  needle  in  thick- 
ened pleura  or  in  an  adhesion,  or  to  blocking  of  the  lumen 
of  the  needle  with  coagula.  Fowler  points  out  that  if  a  per- 
son has  been  recumbent  for  a  long  time  the  upper  layer  of 
fluid  may  be  clear  while  the  lower  layer  is  purulent.^  The 
fluid  should  be  collected  in  a  sterile  glass  tube  and  subjected 
to  a  careful  bacteriological  stud\^ 

Paracentesis  Thoracis. — The  operation  of  tapping  with 
a  trocar  is  no  longer  practised  except  in  an  emergency  when  an 
aspirator  cannot  be  obtained  or  in  an  early  stage  of  non-trau- 
matic pneumothorax.  An  aspirator  is  a  much  better  instrument. 

Aspiration. — Aspiration  consists  in  the  introduction  into 
the  pleural  sac  of  the  tip  of  a  hollow  needle,  the  other  end  of 
which  is  attached  by  means  of  a  rubber  tube  to  a  bottle  from 
which  the  air  has  been  exhausted.  The  fluid  does  not  run 
out,  but  is  sucked  out,  air  is  excluded,  and  bacteria  do  not 
enter  the  pleural  sac.  Fig.  202  shows  a  pneumatic  aspirator. 
No  anesthetic  is  required.  The  skin,  the  instruments,  and  the 
surgeon's  hands  must  be  thoroughly  asepticized.  Gi\'e  the 
patient  a  little  whiskey,  and,  unless  he  is  very  weak,  make  him 
assume  a  semi-erect  attitude.  The  arm  hangs  by  the  side, 
and  the  needle  is  introduced  in  the  fifth  interspace,  just  in 
front  of  the  angle  of  the  scapula.  The  surgeon  marks  the 
upper  border  of  the  sixth  rib  with  the  index-finger,  and 
plunges  in  the  needle  just  above  the  finger,  thus  avoiding 

^  Annals  of  Surgery,  Nov.,  1896. 


736  SURGERY  OF   THE   RESPIRATORY  ORGANS. 


the  intercostal  artery,  which  lies  along  the  lower  border  of 
the  rib  above.  He  guards  the  needle  with  the  index-finger 
to  prevent  its  going  in  too  far.  The  fluid  is  allowed  to  flow 
rather  slowly  in  order  that  the  patient  may  escape  syncope 
and  violent  cough.  If  the  patient  becomes  very  faint,  the 
operation  should  be  abandoned.  All  the  fluid  present  should 
not  be  removed  at  One  sitting — complete  removal  of  a  large 
effusion  is  not  safe.  The  operation  can  be  repeated  if  neces- 
sary. After  withdrawing  the  needle  place  iodoform  collo- 
dion over  the  opening  in  the  chest.  In  an  early  stage  of 
non-traumatic  pneumothorax  perform  paracentesis  without 
suction.  In  pleuritic  effusion,  if  the  lungs  will  not  expand 
after  tappings,  perform  thoracotomy. 

Thoracotomy  is  an  incision  into  the  cavity  of  the  pleura. 
It  may  be  merely  an  intercostal  incision,  or  may  be  an  open- 
ing into  the  chest  after  resecting  a  portion 
of  a  rib.  Often  in  a  child  with  empyema 
good  drainage  can  be  obtained  by  an  in- 
tercostal incision,  but  in  most  children 
and  in  all  adults  a  rib  should  be  resected. 
The  instruments  required  are  a  scalpel,  a 
grooved  director,  forceps  (hemostatic  and 
dissecting-),  scissors,  a  dry  dissector,  re- 
tractors, bone-instruments  (in  case  rib- 
excision  is  required),  drainage-tubes,  and 
needles. 

If  there  is  veiy  little  dyspnea,  ether 
can  be  given.  If  there  is  considerable 
dyspnea,  chloroform  should  be  given.  If  there  is  severe 
dyspnea,  no  general  anesthetic  is  admissible.  In  severe 
dyspnea  the  patient  is  using  certain  voluntary  muscles  to 
aid  him  hi  obtaining  air.  A  general  anesthetic  abolishes 
the  activity  of  the  voluntary  muscles  of  respiration,  and  so 
might  cause  suffocation.  In  such  cases  the  operation  can  be 
done  with  fair  satisfaction  after  the  injection  of  eucain  or  after 
infiltrating  the  superficial  tissues  of  the  chest-wall  with 
Schleich's  fluid,  or,  what  is  better,  aspiration  can  be  per- 
formed. Aspiration  will  permit  of  the  subsequent  adminis- 
tration of  a  general  anesthetic.  The  patient  on  whom  thora- 
cotomy is  to  be  performed  is  placed  supine,  the  diseased  side 
being  at  or  over  the  edge  of  the  table.  He  must  never  be 
placed  on  the  sound  side,  because  he  breathes  only  with  that 
side,  and  pressure  on  it  may  be  dangerous. 

The  arm  of  the  diseased  side  should  be  elevated  to  a  right 
angle  with  the  body.     If  the  surgeon  desires  to  make  only 


Fig.  254. — Resection  of 
a  rib  (Esmarch  and  Kowal- 
zig)- 


THORACOTOMY.  737 

intercostal  drainage,  he  should  make  a  longitudinal  incision 
about  three  inches  in  length  at  the  upper  border  of  the  sixth 
or  seventh  rib,  and  the  middle  of  this  incision  should  cor- 
respond to  the  midaxillary  line.  This  incision  is  earned, 
layer  bv  layer,  to  the  pleura.  If,  as  will  usually  be  the  case, 
he  wishes  to  remove  a  portion  of  a  rib,  he  will  make  an  in- 
cision about  three  inches  in  length  directly  upon  the  outer 
surface  of  the  rib  he  wishes  to  remove,  and  the  middle  ot 
this  incision  corresponds  to  the  midaxillar>'  line.  Some  sur- 
geons resect  a  portion  of  the  fifth  rib,  some  remove  a  bit  oi 
the  eicrhth  rib,  and  Munro  ^  shows  that  at  the  level  of  the 
eicrhth^'rib  there  is  no  danger  of  injuring  the  diaphragm. 
By  many  operators  a  portion  of  the  seventh  or  eighth  rib  is 
removed  in  front  of  the  line  of  the  posterior  axillar)^  fold. 

I  acrree  with  Hutton  that  a  portion  of  the  sixth  rib  in  the 
midaxiUar)^  line  should  be  removed."  The  reasons  given  by 
Hutton  for  the  selection  of  this  region  are:  i.  It  is  over 
the  portion  of  the  lung  which  expands  last.  An  empyema 
is  drained  onlv  partlv  bv  gravity,  and  the  fluid  is  really  forced 
out  and  the  cavit}'  obliterated  by  lung  expansion.  If  an  incision 
is  made  anterior  or  posterior  to  this  point,  the  expanding  ung 
will  block  the  drainage-opening,  and  a  pus-cavity  without 
drainage  will  remain  in  the  midaxillan.^  line.  2.  Such  an  inci- 
sion pei-mits  a  patient  to  lie  on  his  back  without  making  press- 
ure on  the  drainage-tube. 

The  periosteum  of  the  outer  surface  of  the  rib_  must  be 
divided  in  the  same  direction  as  the  superficial  incision.  The 
exposed  rib  is  stripped  of  periosteum  front  and  back  by 
means  of  a  periosteal  separator,  and  with  the  periosteum  at 
the  lower  border  of  the  rib  the  intercostal  artery  is  lifted  out 
of  harm's  way.  The  rib  can  be  divided  by  means  of  cutting 
forceps,  a  chain-saw,  or  a  Gigli  saw.  The  usual  method  is 
to  push  a  periosteal  separator  under  the  rib,  and  saw  the 
bone  in  two  places  by  means  of  a  metacarpal  saw.  An  inch 
or  more  of  rib  should  be  removed.  The  pleura  should  now 
be  opened.  The  opening  of  the  pleura  is  carried  out  m  the 
same  way  in  intercostal  incision  and  after  rib-resection.  A 
crrooved' director  is  pushed  into  the  pleural  sac.  and  the 
Spening  is  enlarged  bv  means  of  the  forceps  and  the  finger. 
The  finger  removes  all  masses  of  tubercular  material  or 
aplastic  Ivmph  within  reach.  If  the  finger  finds  the  lung 
bound  down  with  dense  adhesions  so  that  it  cannot  expand, 

1  TJ/^^iVa/ vV«w,  September  2,  1899.  „..,,,,..     ,   ,  ,  ^^ 

2  See  W.  Menzies  Hutton  on  "  Empyema,"  m  British  Jleaical  Journal,  Uc- 
tober  29,  1898. 

47 


738  SUJiGEI^Y  OF  THE  RESPIRATORY  ORGANS. 

simple  rib-resection  will  not  cure,  and  Estlander's  or  Schede's 
operation  should  be  done.  Some  surgeons  advocate  imme- 
diate irrigation,  but  this  procedure  is  unsafe.  It  is  true  that  in 
most  cases  irrigation  does  no  harm,  but  in  no  case  will  it  sterilize 
the  cavity,  and  in  some  cases  it  is  very  dangerous.  The  pleura 
is  very  susceptible  to  the  action  of  irritants.  This  is  espe- 
cially true  of  young  children.  It  happens  occasionally  that  the 
injection  of  even  the  blandest  fluid  is  followed  by  intense  dysp- 
nea, great  shock,  disturbances  of  respiration  and  circulation, 
convulsions,  and  even  death  (Quenu).  The  convulsions  which 
occasionally  follow  pleural  irrigation  were  called  by  de  Ceren- 
ville  pleural  epilepsy.  In  putrid  empyema  it  is  proper  to 
irrigate.  Irrigation  will  remove  part  of  the  actively  poison- 
ous putrid  matter,  and  the  retention  of  putrid  matter  is  a 
greater  danger  than  irrigation.  It  used  to  be  rather  a  com- 
mon custom  to  make  a  counter-opening  by  cutting  down 
upon  the  long  probe  pushed  against  the  chest-w^all  after 
being  introduced  through  the  incision,  but  a  counter-opening 
is  of  no  particular  use.  A  drainage-tube  about  two  inches  in 
length  is  introduced  and  stitched  in  place.  The  tube  must 
not  be  long  enough  to  touch  against  the  lung.  A  safety- 
pin  is  clamped  upon  the  tube  to  keep  it  from  slipping  into  the 
chest.  A  tape  should  be  fastened  to  each  side  of  the  tube  and 
tied  about  the  chest  to  prevent  it  from  slipping  out.  Arrest 
bleeding,  suture  the  skin,  dress  with  gauze,  Avood-wool,  and 
a  binder,  and  have  the  dressings  changed  as  soon  as  they 
become  soaked  at  one  point.  Several  times  a  day  change  the 
patient's  position.  At  each  change  of  dressings  direct  him  to 
lie  on  the  diseased  side  for  half  an  hour,  and  with  the  foot  of  the 
bed  raised  for  half  an  hour.  Healing  takes  place  by  ascent 
of  the  diaphgram,  expansion  of  the  lung,  and  retraction  of 
the  chest-wall.  Expansion  of  the  lung  is  favored  by  expira- 
tory acts ;  hence  cause  the  patient  several  times  a  day  to 
blow  into  a  wash-bottle  filled  with  water.  Remove  the  tube 
when  the  discharge  becomes  thin  and  scanty  (about  the 
eighth  or  tenth  day,  as  a  rule).  If  the  lung  was  found  bound 
down  with  adhesions  so  that  it  cannot  expand  to  fill  the 
space  vacated  by  the  pus,  perform  the  operation  of  Schede 
or  Estlander.  If  an  empyema  ceases  to  improve  and  re- 
mains stationary  for  four  to  six  weeks  after  it  has  been 
drained,  firm  adhesions  exist. 

Thoracoplasty  (Estlander's  Operation)  is  a  method 
of  thoracoplasty,  and  is  employed  in  old  cases  of  empyema  in 
which  drainage  has  failed,  and  in  cases  with  retracted 
chest-walls,   collapsed    lungs,   thickened    pleura,   and    cavi- 


THORACOPLASTY;   ESTLAXDER' S   OPERATION      739 


tics  whose  ri^ncl  walls  will  not  collapse.  The  procedure 
recognizes  the  fact  that  after  pus  is  evacuated,  if  the 
lung' is  adherent,  it  cannot  expand  to  fill  the  space  once 
occupied  by  fluid,  and  that  the  rigid  chest  cannot  fall  in  as  a 
substitute  for  the  lung.  It  seeks  to  destroy  the  rigidity  of 
the  chest  and  to  permit  it  to  collapse  and  thus  obliterate  the 
cavity  of  the  empyema.  When  the  surgeon  resects  a  rib  and 
finds  a  cavity  with'uncollapsable  walls,  or  a  lung  bound  down 
with  firm  adhesions,  he  should  perform  thoracoplasty.  This 
operation  causes  the  obliteration  of  the  cavity  by  collapsing 
that  portion  of  the  chest-wall  overlying  it.  The  cavity  is  in 
the  upper  or  central  part  of  the  pleural  space  (Treves).  The 
instruments  required  are  the  same  as  those  for  resection 
of  a  rib.  The  position  is  the  same  as  that  for  rib-resec- 
tion. The  length  of  the  incision  depends  on  the  size  of 
the  cavity.  The  surgeon  usually  removes  portions  of  the 
second,  third,  fourth,  fifth,  sixth,  and  seventh  ribs.  Make  a 
transverse  incision  along  the  center  of  an  intercostal  space, 
and  through  this  incision  remove  the  ribs  above  and  below 
by  the  method  set  forth  on  'page  736  (the  removal  of  six 
ribs  will  require  three  incisions).  Instead  of  this  incision,  we 
can  make  a  vertical  incision  or  a  U-shaped  flap.  Always 
take  away  the  periosteum  in  order  to  prevent  reproduction 
of  the  ribs.  Treves  recom- 
mends that  the  cavity  be  at 
once  washed  out  with  corro- 
sive sublimate  (i  :  looo).  In 
cavities  which  are  surrounded 
by  firm  adhesions,  and  in  old 
cases  in  which  the  pleura  is 
greatly  thickened,  irrigation  is 
safe.  If  the  cavity  is  small,  it 
should  be  packed  with  iodo- 
form gauze  and  allowed  to 
granulate ;  if  large,  it  should 
be  drained  by  a  large  tube, 
the  skin  being  sutured  by 
silkworm-gut. 

Sched^'s  Operation. — 
Schede  showed  that  when  the 
pleura  is  much  thickened 
even  Estlander's  operation 
will  not  permit  the  chest-wall 
to  collapse  and  fill  the  cavity 
once  occupied  by  the  fluid. 


Fig.  255.— Incision  for  Schede's  operation  of 
thoracoplasty  (Esmarch  and  Kowalzig). 


The  instruments  used  are  the 


740  SCRCEKY  OF   THE   RESPIRATORY   ORGANS. 

same  as  for  Estlander's  opertion,  plus  bone-shears.  A 
U-shaped  flap  is  made  from  the  level  of  the  axilla  in  front  to 
the  level  of  the  second  rib  and  between  the  scapula  and 
spine  behind.  The  lowest  level  of  this  incision  corresponds 
to  the  lowest  limit  of  the  pleura  (Fig.  255).  The  flap  is  loos- 
ened and  raised,  and  the  scapula  is  lifted  with  it.  The  ribs 
from  the  second  rib  down  and  from  the  costal  cartilages  to 
the  tubercles  are  removed,  along  with  the  intercostal  muscles 
and  the  pleura.  This  is  accomplished  by  cutting  with  bone- 
shears  and  scissors.  Hemorrhage  is  arrested.  The  pleura 
is  curetted.  A  drainage-tube  or  a  piece  of  iodoform  gauze 
is  introduced,  and  the  raw  flap  is  laid  against  the  visceral 
layer  of  the  pleura.  The  superficial  incision  is  sutured, 
except  at  the  point  where  the  tube  or  the  gauze  emerges. 

Pneumotomy  for  Abscess  of  the  I/Ung. — The  instru- 
ments required  are  scalpels,  hemostatic  forceps,  dissecting- 
forceps,  a  dry  dissector,  retractors,  a  periosteum-elevator,  a 
metacarpal  saw,  scissors,  needles  (curved  and  straight),  and  a 
Paquelin  cautery. 

Operation. — Place  the  patient  recumbent  with  the  shoul- 
ders a  little  raised.  Make  a  U-shaped  flap  over  the  seat  of 
disease.  If  the  intercostal  spaces  are  wide,  cut  down  in  a  space 
to  the  pleura.  If  they  are  not  wide,  resect  a  rib.  If  it  is 
found  that  adhesions  do  not  exist  between  the  pulmonary  and 
costal  layers  of  the  pleura,  stitch  these  layers  together  with 
catgut  and  postpone  further  operation  for  forty-eight  hours. 
If  adhesions  exist,  proceed  at  once.  Incise  the  aggluti- 
nated layers  of  the  pleura,  and  pass  an  aspirating-needle 
into  the  lung  in  various  directions.  When  the  abscess  is 
located  open  it  with  the  cautery.  Carry  the  Paquelin  cautery 
slowly  into  the  lung  in  the  direction  of  the  abscess-cavity. 
The  cautery-knife  should  be  at  a  dull-red  heat. 

Fowler  calls  attention  to  the  fact  that  lung-tissue  is  so 
insensitive  that  the  administration  of  ether  can  be  suspended 
as  soon  as  the  pleura  has  been  opened.  When  the  cautery 
opens  the  cavity  of  the  abscess  withdraw  the  instrument  and 
insert  a  drainage-tube  or  a  bit  of  iodoform  gauze,  and  suture 
the  flap  of  superficial  tissue.  If  the  abscess  is  not  found 
after  one  or  two  punctures  with  the  aspirating-ne'edle,  aban- 
don the  attempt. 

Tuffier  explores  for  an  abscess  by  what  he  calls  decolle- 
ment  of  the  parietal  pleura.  He  exposes  the  parietal  layer 
of  the  pleura,  passes  his  hand  between  this  layer  and  the 
chest-wall,  strips  the  pleura  off  over  a  considerable  area,  and 
is  able  to  feel  the  lungf  below  and  thus  determine  its  condition. 


DISEASES    OF   THE   MOUTH,    ETC.  74I 

XXVI.    DISEASES     AND    INJURIES    OF    THE    UPPER 
DIGESTIVE    TRACT. 

Diseases  of  the  Mouth,  Tongue,  and  Bsophagus. 

— Harelip  and  Cleft  Palate. — Harelip  is  a  congenital  cleft 
in  the  ui)pcr  lip  due  to  defective  development.  Cleft  palate 
is  a  congenital  fissure  in  the  soft  palate  or  in  both  the  hard 
and  soft  palates.  In  harelip  the  cleft  is  usually  complete, 
through  the  entire  lip  into  the  nostril,  but  in  rare  cases  it 
may  only  show  as  a  furrow  in  the  mucous  edge  or  as  a  split 
from  the  nostril  partly  into  the  lip.  It  is  most  common  on 
the  left  side.  In  double  harelip  the  central  portion  of  the 
lip  is  often  adherent  to  the  tip  of  the  nose.  Double  harelip 
may  be  free  from  complication,  but  is  often  associated  with  a 
malformation  of  the  alveolus  and  palate.  Median  harelip  is 
exceedingly  rare.  In  cleft  palate  the  septum  of  the  nose  is 
usually  adherent  to  the  palatine  process  opposite  the  side 
upon  which  the  fissure  exists.  In  those  rare  cases  of  cleft 
palate  double  in  front  the  nasal  septum  is  attached  only  to 
the  premaxillary  bone,  and  the  premaxillary  bone  is  not  at- 
tached at.all  to  the  superior  maxillae.  In  harelip  there  is 
often  a  cleft  in  the  alveolus,  and  almost  always  flattening  of 
the  corresponding  side  of  the  nose.  Harelip  is  often  asso- 
ciated with  cleft  palate,  talipes,  and  other  deformities.  It  is  a 
great  deformity,  and  interferes  with  sucking,  swallowing,  and 
articulation. 

Operation  for  harelip  should  be  performed  between  the 
third  and  sixth  months  of  life  in  a  child  in  good  health,  free 
from  stomach  trouble,  cough,  or  coryza,  but  operation  is  not 
advisable  in  the  early  weeks  of  life.  Always,  if  possible, 
operate  before  dentition  begins  (seventh  month).  If  the 
child  is  in  poor  health,  postpone  the  operation  until  restora- 
tion has  so  far  advanced  as  to  render  operation  safe.  While 
waiting  for  operation  be  sure  the  child  is  getting  enough 
food.  If  it  cannot  suck,  feed  it  with  a  spoon.  If  a  cleft 
exists  in  the  palate,  operate  first  upon  the  lip,  because  the 
pressure  of  the  parts  after  the  edges  of  the  gap  are  approxi- 
mated aids  in  the  closure  of  the  bony  cleft.  Cleft  palate 
interferes  with  sucking,  deglutition,  mastication,  and  articula- 
tion. In  severe  cases  the  food  passes  into  the  nose  and 
excites  inflammation.  Loss  of  control  of  the  palate-muscles 
always  exists,  and  liquids  and  solids  are  liable  to  pass  into 
the  windpipe.  Clefts  in  the  hard  palate  should  not  be  oper- 
ated on  until  the  second  year,  but  should  be  operated  upon 
then,  otherwise  speech  will  be  permanently  affected.     Some 


742   DISEASES  AND  INJURIES   OF  DIGESTIVE    TRACT. 

surgeons  refuse  to  operate  until  the  tenth  or  twelfth  year, 
but  operation  done  this  late  will  not  correct  speech-defect 
(Edmund  Owen).  The  patient  at  the  period  of  operation 
should  be  well  and  free  from  cough. 
In  many  cases  the  passage  of  food  and 
drink  into  the  nose  can  largely  be  pre- 
vented by  the  use  of  a  diaphragm. 

Operation  for  Harelip. — The  instru- 
ments required  are  a  tenotome  and 
scalpel,  toothed  forceps,  hemostatic  for- 
ceps, scissors  curved  on  the  flat  and 
'■'-'•  afio7 fortafeifp!  °^"'  pointcd,  Straight  blunt-pointcd  scissors, 
needles  (straight  and  curved),  silver  wire 
or  silkworm-gut  and  silk  sutures,  a  mouth-gag  and  tongue- 
forceps,  a  needle-holder,  and  sequestrum-forceps,  each  blade 
protected  by  a  rubber  tube.  Wrap  the  child  in  a  sheet ;  place 
it  in  the  Trendelenburg  position,  and  rest  the  head  upon  a 
sand-pillow.  The  surgeon  stands  to  the  right  side  of  the 
patient.  Ether  or  chloroform  is  given.  For  single  harelip, 
separate  with  the  scissors  the  upper  lip  from  the  bone  on 
each  side  of  the  cleft  until  approximation  of  the  cleft  can 
be  effected  without  tension.  If  the  maxillary  bone  of  one 
side  projects  more  than  its  fellow,  grasp  it  with  sequestrum- 
forceps  and  bend  it  back  (Jacobson  and  Treves).  Clamp  the 
upper  lip  at  each  angle  of  the  mouth  to  prevent  hemor- 
rhage. If  the  edges  are  of  equal  or  nearly  equal  length, 
and  if  the  gap  is  not  very  wide,  perform  Malgaigne's  oper- 
ation. This  is  performed  as  follows  :  a  flap  is  detached  on 
each  side,  the  detachment  beginning  at  the  upper  angle 
of  the  gap  ;  each  flap  is  detached  above  but  remains  attached 
below.  The  flaps  are  separated  from  the  bone,  and  are 
drawn  downward  so  as  to  form  a  prominence  at  the  ver- 
milion border  (Fig.  256).  If  the  edges  are  pared  so  that 
in  closure  the  vermilion  border  is  even,  when  the  parts  are 
healed  a  gutter  will  be  visible  at  the  line  of  union.  The 
edges  are  approximated  by  an  assistant,  and  silkworm-gut 
sutures  or  silver  wires  are  passed  by  means  of  a  straight 
needle.  Each  suture  goes  down  to  the  mucous  membrane. 
The  first  suture  is  passed  through  the  middle  of  the  lip,  one- 
third  of  an  inch  from  the  cleft.  Three  or  four  main  sutures 
are  passed  through  the  thickness  of  the  lip,  and  are  tied  and 
cut  off.  Two  or  three  fine  silk  or  catgut  sutures  are  passed 
by  a  curved  needle  through  the  vermilion  border  of  the  lip 
and  the  mucous  membrane  of  the  mouth,  and  are  tied  and  cut 
off.    A  small  piece  of  gauze  is  placed  over  the  lip  and  is  held 


DISEASES   OF   THE   MOUTH,    ETC.  743 

in  place  by  straps  of  rubber  plaster.  After  operation  prevent 
the  child  crying  by  feeding  it  often  and  giving  it  small  doses 
of  laudanum.  Heath  orders  two  drops  of  laudanum  in  one 
ounce  of  distilled  water,  a  teaspoonful  to  be  given  every  two 
or  three  hours.  About  the  sixth  day  one-half  the  sutures 
are  taken  out,  and  on  the  eighth  or  ninth  day  the  remaining 
ones  are  removed.  In  many  cases  no  further  procedure  is 
necessary,  but  if  after  some  weeks  the  prominence  at  the  lip- 
border  does  not  shrink,  it  can  be  readily  clipped  away. 
Harelip-pins  are  not  used  at  the  present  time,  and  are  not 
needed  if  the  lip  is  well  separated  from  the  bone.  If  the  edges 
of  the  cleft  are  of  unequal  length,  Edmund  Owen's  oper- 
ation can  be  performed  (see  below,  under  Double  Harelip),  or 
we  can  perform  Mirault's  operation,  as  shown  in  Fig.  258. 

In  double  harelip  the  operation  is  similar  to  that  for  smgle 
harelip.  If  the  intervening  piece  is  vertical  and  is  covered  with 
healthy  skin,  complete  each  operation  as  for  single  harelip, 
closing  both  fissures  at  once  with  silver  wire  in  a  strong, 
healthy  child,  closing  them  at  intervals  of  three  weeks  in  one 
not  so  lu.sty  (Fig.  257).     Excise  the  septum  if  it  is  deformed 

The  premaxillar}^  bone    should 
in  most  instances  be   removed, 


Fig   2S7.-Incisions  for  double  barelip  Fig.  ssS.-Mirauh's  operation  for  single 

■     (EsmarchandKowalzig).  harelip  (Esmarch). 

the  skin  over  it  being  preser\^ed.  Sir  Wm.  Fergusson  was 
accustomed  to  incise  the  mucous  membrane  and  shell  out 
this  bone.  The  premaxillary  bone  can  be  forced  back  mto 
line,  being  held,  if  necessary,  by  catgut  suture  of  the  peri- 
osteum ;  but  if  saved  it  is  liable  to  necrose  and  its  teeth  soon 
decay.  '  Heath  removes  this  bone  two  weeks  before  operating 
on  the  lip.  If  there  is  much  hemorrhage  after  removal  of  the 
bone,  arrest  it  with  a  hot  wire  or  with  Horsley's  wax.  Fig. 
257  shows  incisions  for  double  harelip.  Edmund  Owen's 
operation  is  very  useful  (Figs.  259,  260).  In  this  operation 
ver>^  thick  flaps  are  cut.  The  prolabium  and  incisive  bone 
are  removed.  The  flaps  are  cut  as  shown,  Fig.  259,  on  one 
side  by  line  ab,  and  on  the  other  side  by  line  cde.     a  is 


744   DISEASES  AND   INJURIES   OE  DIGESTIVE    TRACT. 


brought  to   c,  b  is   brought  to    d,  f  is  brought  to  c,  and 
sutures  are  appHed  (Fig.  260). 

Operation  for  Cleft  Palate. — It  is  true  that  during  the  early 
years  of  growth  a  cleft  diminishes  in  size  ;  but  to  wait  too 
long  before  we  operate  means  permanent  speech-impairment. 
Bony  clefts  should  be  operated  upon 
during  the  second  year.     Clefts  of 
the  soft  palate  only  may  be  operated 


Fig.  259. — Double  harelip,  the  prolabium  and         Fig.  260. — The  two  sides  of  the  lip  drawn 
incisive  bone  having  been  removed  (Owen).  together  and  secured  by  sutures  (Owen). 


upon  during  the  first  six  months.  If  both  the  hard  and  soft 
palates  are  cleft,  close  both  at  one  operation.  Edmund  Owen 
has  recently  put  forth  a  convincing  plea  for  early  operation.^ 
He  says  he  is  operating  earlier  and  earlier,  and  quotes  Chil- 
ton as  the  gentleman  who  led  him  to  do  so.  Owen  main- 
tains that  if  speech  is  to  be  improved  operation  must  be  done 
early,  and  he  formulates  some  very  valuable  rules  of  prep- 
aration and  care :  Have  the  child  in  the  best  condition, 
free  from  cough  and  stomach  disorder.  Operate  in  the 
summer.  Place  the  child  under  the  charge  of  a  nurse 
several  days  before  the  operation.  For  suture  of  the  soft 
palate  {staphylorrhaphy)  Treves  says  the  following  instru- 
ments are  essential :  two  sharp-pointed  tenotomes,  a  blunt- 
pointed  tenotome,  a  rectanglar  knife,  two  pairs  of  long  forceps 
(one  with  tenaculum  points,  one  serrated),  a  fine  hook,  a  pair 
of  sharp-pointed  curved  scissors,  scissors  curved  on  the  flat, 
periosteum-elevators,  two  long-handled  needles  with  eyes  at 
their  points,  a  suture-catcher,  a  tubular  needle  for  wire  su- 
tures, hemostatic  forceps.  Whitehead's  gag  and  retractors, 
silver  wire,  silkworm-gut,  and  sponge-holders ;  also  an  elec- 
tric forehead-light.  The  patient's  body  may  be  raised,  with 
his  head  elevated  and  rested  upon  a  sand-bag.  A  better  posi- 
tion is  that  of  Trendelenburg,  as  it  prevents  the  trickling 
of  blood  into  the  windpipe.  Chloroform  is  given.  The  gag 
is  introduced;  the  edges  of  the  mucous  membrane  are  pared 
with  a  tenotome ;  the  sutures  are  introduced  from  below  up- 
ward, silkworm-gut  being  used  for  the  uvula  and  lower  part 

1  Lancet,  Jan.  4,  1S96. 


DISEASES   OF   THE  MOUTJI,    ETC. 


745 


of  the  velum,  silver  wire  for  the  remainder  of  the  cleft;  each 
suture,  as  it  is  passed,  is  tied  or  twisted,  but  is  not  cut  until 
the  next  suture  is  inserted,  and  serves  as  a  handle.  If 
there  is  too  much  tension  to  allow  of  the  sutures  being  tied 
as  they  are  inserted,  all  the  sutures  are  passed  and  loosely- 
twisted.  A  longitudinal  incision  is  made  upon  each  side,  in- 
ternal to  the  hamular  process,  the  mucous  membrane  being 
cut  with  a  sharp  tenotome,  the  deeper  structures  being  di- 
vided with  a  blunt  tenotome  ;  the  sutures  are  tied  or  twisted 
and  cut  (Fig.  261).  In  Fergtcsson' s  operatiojt  for  cleft  of  the 
hard  palate  {tiranoplast}/)  the  mucous  edges  are  pared  and 
the  sutures  inserted  but  not  tied.  Make  an  incision  upon 
each  side  down  to  the  bone,  the  incision  being  midway  be- 
tween the  cleft  and  the  alveolus.  Divide  the  bone  on  each 
side,  by  means  of  a  chisel,  to  the  full  length  of  the  incision, 
and,  using  the  chisel  as  a  lever,  force  each  half  of  the  bone 
toward  the  gap.  Tie  the  sutures,  and  plug  each  lateral  in- 
cision with  a  piece  of  iodoform  gauze  (Fig.  262).  After  the 
operation  for  cleft  palate  put  the  patient  to  bed  for  otie  week  ; 
forbid  talking  ;  give  fluid  or  semisolid  food  at  intervals  of  two 
or  three  hours  for  three  weeks ;  wash  out  the  mouth  very 


Fig.  261. — Staphylorrhaphy  (Esmarch 
and  Kowalzig). 


Fig.  262. — Uranoplasty  (Esnaarch 
and  Kowalzig). 


often  (always  after  eating)  with  a  carbolic  solution  (i  :  lOO), 
a  solution  of  boric  acid,  or  Condy's  fluid.  Sutures  are  re- 
moved in  from  two  to  three  weeks. 

Edmund  Owen  ^  operates  as  follows :  pare  a  strip  of 
mucous  membrane  from  each  side  of  the  fissure  from  the  tip 
of  the  uvula  to  the  top  of  the  gap.  Make  a  free  incision 
"  along  the  alveolar  aspect  of  the  palate  "  close  to  the  teeth. 
Lift  up  the  strips  of  mucoperiosteum  and  shift  them  toward 
the  cleft.  Sever  the  attachments  of  the  soft  palate  to  the 
posterior  border  of  the  hard  palate  and  extend  the  alveolar 

'  Lancet,  Jan.  4,  1896. 


746   DISEASES  AND   INJURIES   OE  DIGESTIVE    TRACT. 

incision  well  backward.  This  incision  relieves  tension.  Sew 
up  with  wire ;  twist  and  cut  each  wire,  leaving  an  end  one- 
eighth  of  an  inch  long.  This  procedure  causes  the  child  to 
keep  his  tongue  from  the  suture-line.  For  the  first  twenty- 
four  hours  give  only  water,  and  after  this  period  feed  with 
beef-jelly  and  liquids. 

When  feeding  is  begun  attempt  irrigation  or  spraying  if 
it  does  not  alarm  the  child,  In  a  day  or  two  the  patient  can 
take  sweetened  orange-juice,  custard-pudding,  finely  sieved 
meat  or  chicken.  The  best  fluid  for  irrigation  is  Condy's 
fluid  or  mild  carbolic  acid. 

Get  the  child  out  in  the  air  a  day  or  two  after  the  oper- 
ation and  keep  it  out  all  day.  (The  entire  article  of  Mr. 
Owen  will  well  repay  a  careful  reading.) 

Carcinoma  of  the  Lower  Lip. — Cancer  commonly  arises 
in  the  lower  lip,  very  rarely  in  the  upper  lip.     Males  suffer 


Fig.  263 — Grant's  operation  for  carcinoma  of  the  lip. 

frequently,  but  females  are  not  very  often  attacked.  In  some 
cases  it  seems  to  arise  in  smokers  at  the  point  on  the  lip 
where  the  pipe  habitually  rested.  A  short-stemmed  clay 
pipe,  which  grows  hot  when  it  is  smoked,  is  particularly  apt 
to  lead  to  the  growth  of  cancer.  The  region  in  the  lip  which 
is  most  liable  to  cancer  is  the  junction  of  the  skin  and  mucous 
membrane.  The  growth  may  begin  in  a  fissure  or  abrasion, 
may  start  in  an  eczematous  area,  but  most  frequently  arises 
as  an  indurated  area  which  quickly  ulcerates.  After  a 
cancer  has  existed  for  a  variable  time  the  submental  and 
submaxillary  lymphatic  glands  become  diseased.  This  in- 
volvement cannot  be  detected  by  external  manipulation  in  the 
earliest  stages;  hence  it  is  not  proper  to  conclude  that  gland- 
ular involvement  is  absent  simply  because  it  cannot  be  pal- 
pated. It  occasionally  happens  that  glands  enlarge  because 
of  septic  absorption,  and  this  enlargement  may  even  precede 
carcinomatous  involvement.    From  an  operative  point  of  view 


DISEASES   OF   THE   MOUTH,    ETC. 


747 


the  glands  should  always  be  regarded  as  carcinomatous.  If 
cancer  is  not  operated  upon,  it  destroys  the  lip,  involves  the 
glands  of  the  neck  extensiveh-,  the  floor  of  the  mouth,  the 
periosteum  and  lower  jaw,  and  produces  death  in  from  three 
to  five  years.  If  the  jaw  is  involved,  the  prognosis  is  bad, 
and  it  is  practically  hopeless  if  the  floor  of  the  mouth  is  in- 
volved. 

Trcatvicnt. — The  treatment  consists  in  the  early  and  thor- 
ough removal  of  the  growth  with  the  knife,  and  also  in  the 
removal  of  the  fatty  tissue  and  glands  from  the  submaxillary 
triangle  and  from  the  submental  region.  The  growth  must 
be  thoroughly  removed,  that  is,  the  incision  must  be  at  least 
half  an  inch  wide  of  the  disease.  Thorough  early  removal 
w^ill  cure  about  50  per  cent,  of  cases.  For  many  years  a 
favorite  operation  has  been  the  V-shaped  incision,  the  skin- 
edges  being  sutured  by  silkworm-gut,  the  sutures  being 
passed  almost  to  the  mucous  membrane  and  being  inserted 
so  as  to  compress  the  vessels  when  tied,  and  the  mucous 
membrane  being  sutured  with  fine  silk  or  catgut.  The  V- 
shaped  incision  should  only  be  used  for  a  small  growth. 
After  the  removal  of  the  growth  from  the  lip  a  vertical  in- 
cision is  made  from  the  point  of  the  V  over  the  cricoid  carti- 
lage, and  from  the  origin  of  this  incision  incisions  are  made 
in  each  direction  alonsr  the  under  surface  of  the  bodv  of  the 


FiG.  264. — Removal  of  lower  lip  and  cheilo- 
plasty  (Esmarch  and  Kowalzig). 


Fig.   265. — Suturing  in  cheiloplasty  (Es- 
march and  Kowalzig). 


jaw.  The  glandular  area  is  thus  exposed,  and  after  the  removal 
of  the  fat  and  glands  the  wound  is  sutured  with  silkworm- 
gut.  Better  than  the  V-shaped  incision  is  the  method  devised 
by  W.  W.  Grant  of  Denver.^  In  this  operation  the  growth 
is  removed  and  cheiloplast}'  is  performed.  This  operation 
secures  a  larger,  less  rigid,  and  more  useful  lip  than  does  the 
older  method.  In  this  operation  the  grow^th  is  removed  by 
two  perpendicular  incisions  and  a  transverse  cut  (Fig.  263). 
^  Medical  Record,  May  27,  1899. 


748   DISEASES  AND   INJURIES    OE  DIGESTIVE    TRACT. 

From  each  lower  angle  of  the  wound  an  oblique  incision, 
is  made  (Fig.  263,  b  c,  c  /),  and  these  incisions,  if  carried 
below  the  jaw,  permit  the  removal  of  lymph-glands.  The 
flaps  are  sutured  as  shown  in  Fig.  263. 

In  a  case  in  which  the  lip  is  extensively  involved  the  entire 
lip  should  be  removed  and  a  new  lip  should  be  taken  from 
sound  tissue  and  fastened  in  place.  This  operation  is  shown 
in  Figs.  264  and  265. 

Tong-ue-tie  is  a  congenital  shortness  of  the  frenum.  The 
tongue  cannot  be  protruded  beyond  the  incisor  teeth.  Swal- 
lowing is  interfered  with,  and  later  in  life  articulation  is 
impeded.  Treat  tongue-tie  by  tearing  up  the  frenum  with  the 
thumb-nail.  If  this  fails,  catch  the  frenum  in  the  slit  in  the 
handle  of  a  grooved  director,  push  the  director  toward  the 
base  of  the  tongue,  and  knick  the  frenum  with  scissors 
curved  on  the  flat  and  pointed  toward  the  floor  of  the  mouth. 
The  frenum  should  be  knicked  nearer  the  floor  of  the  mouth 
than  to  the  tongue. 

Ranula  is  a  retention-cyst  of  the  duct  of  the  submaxillary 
or  the  duct  of  the  sublingual  gland.  A  ranula  when  first  formed 
contains  saliva,  but  after  a  time  the  saliva  undergoes  a  change, 
and  in  appearance  comes  to  resemble  mucus.  Mucous  cysts 
occur  in  the  floor  of  the  mouth,  resulting  from  obstruction 
of  the  ducts  of  the  mucous  glands  of  Nuhn  and  Blandin. 
These  glands  lie  on  each  side  of  the  frenum  of  the  tongue. 
Such  a  cyst  is  often  spoken  of  as  a  ranula.  A  ranula  appears 
upon  the  floor  of  the  mouth  on  one  side  and  pushes  the 
tongue  toward  the  opposite  side.  The  contents  of  a  ranula 
resemble  mucus  or  saliva.  The  treatment  of  a  mucous  cyst 
is  by  excision  of  a  portion  of  the  cyst-wall  and  cauterization 
of  the  interior  with  pure  carbolic  acid ;  or  by  cutting  a  flap 
from  the  cyst-wall  and  stitching  it  aside  so  as  to  keep  a  per- 
manent opening.  Such  an  operation  may  cure  a  genuine 
ranula,  but  will  often  fail.  In  true  ranula  an  external  incision 
should  be  made,  and  through  this  both  the  cyst  and  the  gland 
should  be  removed.     This  plan  is  recommended  by  Mintz.^ 

Carcinoina  of  the  Tongue. — This  is  one  of  the  most 
dreadful  forms  of  cancer.  It  is  quite  a  common  disease.  It 
begins,  as  a  rule,  near  the  tip,  on  the  side  or  at  the  base  of 
the  anterior  two-thirds  of  the  tongue,  as  an  ulcer  having  at 
first  a  papillary  structure,  as  a  fissure  which  indurates,  or  as 
an  indurated  area  which  ulcerates.  The  cause  of  the  growth 
may  sometimes  be  traced  to  the  irritation  of  a  jagged  tooth, 
or  to  the  smoking  of  a  pipe,  or  to  holding  nails  in  the  mouth, 

*  Zeitschrift fur  Chirurgie,  March,  1899. 


DISEASES    OF   THE   MOUTH,    ETC.  749 

as  is  done  by  those  who  nail  laths.  Cancer  may  follow  a 
chronic  inflammation — leukoplakia,  for  instance.  As  in  cancer 
of  the  lip,  men  are  much  more  frequently  affected  than  wo- 
men. In  most  cases  the  disease  spreads  rapidly ;  produces 
early  and  extensive  glandular  involvement;  disease  of  the 
floor  of  the  mouth  ;  dribbling  of  saliva  ;  difficulty  in  masticat- 
ing, swallowing,  and  talking ;  foulness  of  the  breath  ; 
severe  pain  which  usually  radiates  toward  the  ear,  and  often 
a  fatal  septic  trouble.  Cases  not  operated  upon  usually  die 
within  two  years.  There  is  a  very  rare  form  of  carcinoma 
described  by  Wolfler,  which  grows  very  slowly  or  even  re- 
mains latent  for  years. 

One  reason  why  cancer  of  the  tongue  grows  so  rapidly 
has  been  pointed  out  by  Heidenhain  of  Greifswald.  The 
lingual  muscles  are  contracting  almost  constantly,  and  as  a 
result  cancer-cells  are  forced  along  the  lymph-spaces  to 
healthy  areas. 

Treatment. — A  cancer  of  the  tongue  should  be  removed 
radically  at  the  earliest  possible  moment.  Before  any  opera- 
tion is  undertaken  all  stumps  of  teeth  should  be  removed. 
For  several  days  before  an  operation  the  teeth  should  be 
scrubbed  twice  a  day  with  a  brush  and  soap,  and  the  mouth, 
nares,  and  nasopharynx  should  be  sprayed  with  peroxid  of 
hydrogen  and  then  with  boric-acid  solution  every  second  or 
third  hour  when  the  patient  is  awake. 

In  this  disease  not  only  the  tongue,  but  also  the  adjacent 
lymphatic  glands  must  be  removed.  The  lymph-vessels 
from  the  tongue  pass  to  the  submaxillary  and  deep  cervical 
lymphatic  glands. 

In  a  very  recent  and  limited  case  only  the  glands  on  the 
diseased  side  require  removal ;  in  an  advanced  case  the 
glands  must  be  removed  from  both  sides  of  the  neck,  because 
it  has  been  shown  by  Kuttner  of  Tubingen  that  lymph  from 
one  side  of  the  tongue  may  flow  to  glands  on  the  same  side, 
of  the  neck  ;  but  some  also  may  flow  to  the  opposite  side  of 
the  tongue.  Two  operations  are  to  be  considered  :  partial 
removal  and  complete  removal. 

Partial  Removal  of  the  Tongue. — This  operation  is  re- 
stricted to  recent  cases  in  which  one  side  only  of  the  an- 
"terior  portion  of  the  tongue  is  involved.  The  operation  does 
not  offer  as  good  a  chance  of  cure  as  complete  excision,  be- 
cause lymph  containing  cancer-cells  may  have  reached  the 
opposite  side  of  the  tongue.  In  partial  removal  the  glands 
must  be  removed  from  the  side  which  is  diseased.  If  the 
case    is    sufficiently   advanced    to  require  removal    of   the 


750  DISEASES  AND   INJURIES   OF  DIGESTIVE    TRACT. 


glands  from  both  sides  of  the  neck,  the  tongue  should  be 
completely  removed. 

In  performing  the  operation  of  partial  excision  introduce  a 
mouth-gag,  place  a  silk  ligature  on  each  half  of  the  tip  of 
the  tongue,  and  draw  the  tongue  out  of  the  mouth  (Barker). 
Place  the  patient  in  the  Trendelenburg  position.  Split  the 
tongue  back  in  the  middle  line  with  the  scissors,  and  loosen 
the  cancerous  side  from  the  floor  and  side  of  the  mouth. 
Pass  a  stout  silk  ligature  through  the  base  of  the  tongue 
posterior  to  the  cancer.  Draw  the  organ  out  and  cut  off  the 
diseased  side  in  front  of  the  ligature  but  back  of  the  disease. 
Tie  the  vessels,  remove  the  constricting  and  traction  threads, 
and  treat  subsequently  as  in  cases  of  complete  removal. 

CoTnplete  Removal  of  the  Tongue  {Kocher's  Method). — 
Kocher  used  to  employ  a  preliminary  tracheotomy  in  tongue- 
excision,  but  the  Trendelenburg  position  renders  this  proced- 
ure unnecessary  so  far  as  fear  of  the  passage  of  blood 
into  the  larynx  and  trachea  is  concerned.  The  instru- 
ments required  are  a  scalpel,  retractors,  a  dry  dissector, 
hemostatic  and  dissecting-forceps,  a  tenaculum,  aneurysm- 
needle,  tenaculum-forceps,  needles,  sutures,  and  scissors.     In 

this  operation  the  patient  is 
placed  in  the  Trendelenburg 
position,  the  surgeon  standing 
to  the  affected  side.  Chloro- 
form is  given.  Ligate  the  lin- 
gual artery  on  the  side  opposite 
to  the  one  where  the  main  inci- 
sion is  to  be  made.  Remove  the 
glands  on  that  side  and  suture 
the  wound.  An  incision  is  then 
made  on  the  side  opposite  to 
that  on  which  the  artery  was 
ligated.  This  incision  passes 
from  behind  the  lobe  of  the  ear, 
along  the  anterior  edge  of  the 
sternocleidomastoid  to  about  the  middle  of  the  margin  of 
this  muscle.  From  this  point  the  incision  is  carried  to  the 
level  of  the  hyoid  bone  and  then  to  the  symphysis  menti, 
along  the  anterior  belly  of  the  digastric  muscle  (Fig.  266). 
The  flap  is  dissected  and  turned  up ;  the  facial  and  lingual 
arteries  are  ligated ;  "  the  submaxillary  fossa  is  evacuated  " 
(Treves) ;  the  sublingual  and  submaxillary  glands  are  re- 
moved ;  the  mylohyoid  muscle  is  divided ;  the  mucous  mem- 
brane is  incised  clo.se  to  the  jaw,  and  the  tongue,  caught  with 


Fig.  266. — Kocher's  excision  of  tongue 
(Esmarch  and  Kowalzig). 


DISEASES   OF   THE   MOUTH,    ETC.  75 1 

tenaculum-forccps,  is  drawn  through  the  opening.  The 
tongue  is  spHt  in  the  middle  with  scissors,  and  the  near  half 
is  removed,  bleeding  is  arrested,  the  remaining  half  of  the 
tongue  is  cut  through,  and  the  vessels  are  tied.  Stitch  the 
mucous  membrane  of  the  stump  to  the  mucous  membrane 
of  the  floor  of  the  mouth  with  catgut  sutures.  Kocher  does 
not  suture  the  skin-wound;  many  surgeons  do  suture  it 
and  employ  drainage-tubes.  Some  hours  after  the  operation, 
when  oozing  has  ceased,  dust  the  mouth-wound  with  iodo- 
form. The  patient,  as  soon  as  possible,  is  propped  up  in  bed, 
and  he  must  not  swallow  the  discharges  if  it  can  be  avoided. 
The  mouth,  every  half  hour,  is  sprayed  with  peroxid  of 
hydrogen  and  washed  with  a  carbolic  solution  (i  :  6o). 
Every  three  hours  after  washing  the  floor  of  the  mouth  and 
the  stump  the  parts  should  be  dried  with  absorbent  cotton 
and  dusted  with  iodoform.  For  twenty-four  hours  after  the 
operation  nothing  is  given  by  the  mouth  except  a  little 
cracked  ice,  the  patient  being  fed  per  rectum.  At  the  end 
of  twenty-four  or  forty-eight  hours  some  liquid  food  is 
given  from  a  feeding-cup.  The  patient  will  soon  learn  to 
swallow ;  but  if  he  cannot  swallow  easily,  he  is  fed  Avith  a 
tube.  Treves,  in  his  clear  and  positive  directions  for  after- 
treatment,  states  that  nutrient  enemata  are  to  be  continued 
until  sufficient  nourishment  is  taken  by  the  mouth;  that 
the  mouth  should  be  flushed  by  irrigation,  and  must  be 
washed  immediately  after  taking  food  ;  that  morphin  is  to  be 
avoided ;  and  that  the  patient  can  usually  leave  the  hospital 
in  from  seven  to  ten  days. 

Whitehead's  Operation. — Whitehead  removes  the  entire 
tongue  from  within  the  mouth  by  the  use  of  scissors.  He 
passes  a  ligature  through  the  tip,  cuts  the  frenum,  draws  the 
tongue  strongly  forward,  and  separates  by  a  series  of  clips 
with  the  scissors.  The  lingual  arteries  are  tied  as  cut.  "  The 
stump  should  be  kept  under  control,  as  regards  hemorrhage, 
by  a  stout  silk  ligature  passed  through  the  remains  of  the 
glosso-epiglottidean  fold  and  retained  for  twenty-four  hours."  ^ 
Heath  has  shown  that  if  the  forefinger  be  passed  to  the 
epiglottis  and  used  to  "  hook  forward  "  the  hyoid  bone,  the 
lingual  arteries  are  stretched  and  portions  of  the  tongue  can 
be  removed  almost  without  bleeding.  It  is  rarely  desirable, 
except  in  Kocher's  operation,  to  remove  the  glands  and  the 
tongue  at  one  seance.  To  do  so  increases  shock  and  the 
danger  of  death.  The  rule  of  procedure  set  forth  by  W. 
Watson  Cheyne  ^  is  eminently  wise.     This  rule  is  as  follows  : 

1  American  Text-book  of  Surgery.         ^  The  Practitioner,  April,  1899. 


752    DISEASES  AND   INJURIES   OF  DIGESTIVE    TRACT. 

If  glandular  involvement  is  trivial  or  not  detectable,  it  is 
perfectly  proper  to  remove  the  tongue  first,  and  after  a 
week  or  so  remove  the  glands.  If  the  glandular  involve- 
ment is  marked,  growth  in  the  glands  will  be  much  more 
rapid  than  growth  in  the  tongue.  In  such  a  case  the  glands 
should  be  removed  before  the  tongue,  because,  if  the  tongue 
is  removed  before  the  triangles  are  cleared,  in  the  week  or 
two  of  waiting  the  case  may  become  inoperable.  In  the 
majority  of  cases  clear  out  the  triangles  before  removing  the 
tongue,  doing  the  other  operation  in  one  or  two  weeks  when 
the  wound  in  the  neck  is  healed.  If  the  disease  in  the 
mouth  is  far  advanced,  do  both  operations  at  one  seance. 

Stricture  of  the  Esophagus. — Fibrous  or  cicatricial  strict- 
ure is  due  to  the  healing  of  an  ulcer,  and  results  from  trau- 
matism, chronic  inflammation,  syphilis,  tuberculosis,  chronic 
ulcer,  prolonged  vomiting,  variola,  gout,  or  to  swallowing  a 
corrosive  substance  or  a  boiling  liquid.  It  is  commonest  in  the 
young,  and  is  apt  to  be  situated  opposite  the  cricoid  cartilage, 
at  the  tracheal  bifurcation  or  near  the  cardiac  end.  Cicatri- 
cial strictures  are  usually  single,  but  may  be  multiple. 
Stricture  following  impaction  of  a  foreign  body  is  located  at 
the  seat  of  impaction  unless  the  tube  has  been  injured  by 
efforts  at  extraction,  in  which  case  multiple  strictures  may 
exist  (Maylard).  Strictures  which  result  from  swallowing 
boiling  fluid  or  corrosive  liquid  are  usually  very  extensive, 
and  may  be  multiple.  Syphilitic  stenosis  is  due  to  the 
healing  of  a  gummatous  ulceration,  but  there  is  nothing 
characteristic  in  this  kind  of  stenosis.  Tubercular  stenosis 
is  extremely  rare. 

Symptoms  of  Cicatricial  Stenosis. — The  condition  may 
occur  at  any  age.  The  chief  symptom  is  difficulty  in  swal- 
lowing, at  first  slight,  but  becoming  more  and  more  pro- 
nounced until  swallowing  is  almost  or  quite  impossible.  The 
dysphagia  is  first  manifested  to  dry  solids,  then  to  all  solids, 
and  finally  to  liquids.  In  some  cases  vomiting  occurs  after 
swallowing.  If  the  stricture  is  high  up,  the  vomiting  is 
almost  immediate ;  if  it  is  low  down,  the  vomiting  is  delayed, 
especially  if  the  canal  is  dilated  above  the  stricture.  From 
time  to  time  the  patient  vomits  independently  of  taking  food, 
the  ejected  matter  being  saliva.  The  vomited  matter  is  not 
bloody.  The  patient  feels  weak  and  hungry,  becomes 
exhausted  and  emaciated,  and  suffers  from  flatulence,  gas- 
tralgia,  and  constipation. 

There  is  occasionally  slight  uneasiness  or  even  pain  in  the 
region  of  the  stricture,  possibly  "  about  the  epigastrium  or 


DISEASES   OF   THE  MOUTH,    ETC. 


753 


between  the  shoulder-blades"  (May lard).  The  stricture 
may  be  located  with  a  bougie.  The  history  of  the  case  is  of 
much  importance  in  diagnosis.  The  surgeon  must  inquire 
about  impaction  of  a  foreign  body,  or  swallowing  of  acids, 
alkalies,  or  boiling  fluids  ;  and  must  examine  for  evidence  of 
syphilis.  If  there  is  no  history  of  injury  or  syphilis,  and  the 
patient  is  over  forty  years  of  age,  the  indications  point  to 
cancer  rather  than  cicatricial  stenosis.  The  easy  passage  of 
a  bougie  when  the  patient  is  anesthetized  shows  that  spasm 
is  the  cause,  and  not  organic  disease.    Narrowing  due  to  ex- 


FiG.   267. — Esophageal    instruments  :  a,  b,  forceps  ,  c,  horsehair  probang  ;  D,  coin-catcher  ; 
E,  esophageal  bougie. 


ternal  pressure  is  marked  by  positive  symptoms  of  the  causa- 
tive disease.^ 

Treatment. — Gradual  dilatation  through  the  mouth  is  a 
method  employed  for  at  least  a  time  in  almost  every  case. 
Begin  with  the  largest  bougie  which  will  easily  pass.  Warm 
the  bougie,  oil  it,  pass  it  gently,  and  hold  it  in  position  for 
several  minutes,  prolonging  the  time  of  retention  of  the 
bougie  as  treatment  progresses.  Pass  an  instrument  every 
second  or  third  day,  gradually  increasing  the  size.     If  the 

See  the  excellent  article  in  Maylard's  Surgery  of  the  Alimentary  Canal. 
48 


754   DISEASES  AND   INJURIES   OF  DIGESTIVE    TRACT. 

Stenosis  involves  a  considerable  portion  of  the  esophagus, 
gradual  dilatation  will  almost  certainly  fail  to  cure. 

Symonds  advocates  the   insertion  of  a  tube  through  the 
stricture  and  leaving  it  in  place  until  there  is  decided  dilatation, 
and  then  replacing  the  tube  with  a  larger  instrument.     The 
patient  is  fed  through  the  tube.    Gradual  dilatation  from  below 
has  been  practised  in  cases  where  a  bougie   could    not  be 
passed  from  the  mouth.     A  gastrostomy  is  performed,  and 
after  the  fistula  has   become  sound  the  patient  is   made  to 
swallow  "  a  shot  to  which  is  attached  a  silk  thread  "  (May- 
lard).     The  silk  thread  is  brought  out  through  the  fistulous 
orifice  and  is  attached  to  a  bougie,  and  the  dilating  instru- 
ment is  pulled  up  through   the  esophagus.     Forcible  dilata- 
tion  can   be   employed  through   the    mouth   or  through  a 
gastrotomy  opening  by  means  of  bougies,  tents,  or  divulsing 
instruments.    Electrolysis  is  used  by  Fort  and  others.    Some 
surgeons  perform  internal  esophagotomy  through  the  mouth 
with  a  special  instrument.     A  fibrous  stenosis  in  the  region 
of  the  cricoid  cartilage'  should  be  treated  by  the  operation 
of  external  esophagotomy.     In  this  operation  the  stricture  is 
divided  by  a  longitudinal  incision  ;  "  funnel-shaped  retraction 
of  the   cut    portion    is    caused  by  adhesion  to  the  external 
tissues  divided,  and  it  lessens  future  contraction."^      If  dilata- 
tion fails  in  the  case  of  a  stenosis  above  the  line  of  the  aortic 
arch,  the  esophagus  is  opened  above  the  stricture  (external 
esophagotomy),    a    tenotome    is    introduced     through    the 
wound,  the  stricture  is  cut  and  well   dilated   by  the  passage 
of  instruments.     This  operation  is  known  as  Gussenbauer's 
combined  esophagotomy. 

If  a  stricture  is  impassable  from  above,  the  stomach  should 
be  opened  and  retrograde  dilatation  be  carried  out.  A  firm, 
non-dilatable  stricture  in  the  thoracic  portion  of  the  esopha- 
gus can  be  treated  by  Abbe's  method.  He  performs  a 
gastrotomy,  passes  a  conical  rubber  bougie  from  the 
stomach  into  the  mouth,  ties  a  piece  of  braided  silk 
to  the  bougie,  withdraws  the  instrument  and  leaves  the 
silk  in  place.  One  end  of  the  silk  emerges  from  the 
mouth  and  the  other  end  from  the  gastrotomy  wound. 
In  some  cases  he  opens  the  stomach  and  also  opens 
the  esophagus  above  the  stricture;  one  end  of  the  string 
comes  out  of  the  esophagotomy  wound  and  the  other 
end  out  of  the  gastrotomy  wound.  The  string  is  used  as  a 
string-  or  bow-saw,  the  stricture  is  divided,  the  silk  is  with- 

1  W.  J.  }Aa.yo,  Jou?'na I  American  Medical  Association,  July  29,  1899. 


DISEASES    OF   THE   MOUTH,    ETC.  755 

drawn,  full-sized  bougies  are  passed,  and  the  wound  or 
wounds  are  sutured. 

Ochsner's  operation  is  thus  described  by  Mayo:'  "The 
anterior  wall  of  the  stomach  is  drawn  out  of  a  left  oblique 
incision  through  the  abdominal  coverings ;  a  small  opening 
is  made  into  the  stomach  sufficient  in  size  to  introduce  the 
finger.  A  whalebone  probe,  to  the  tip  of  which  a  silk  string 
guide  has  been  tied,  is  now  passed  through  the  esophagus 
either  from  above  or  retrograde,  as  in  the  Abbe  method. 
With  this  guide  a  loop  of  silk  is  drawn  out  of  the  gastric 
incision  in  such  manner  as  to  leave  the  guide  as  a  third 
string.  Into  this  loop  a  small  soft-rubber  drainage-tube 
three  feet  or  more  in  length  is  caught  in  the  middle  by 
traction  on  tlie  ends  of  the  doubled  thread  through  the 
mouth ;  this  loop  of  rubber  tube  is  drawn  through  the  stom- 
ach and  made  to  engage  in  the  stricture. 

"  The  greater  the  amount  of  traction  the  smaller  the 
stretched  rubber  tube,  until  it  is  sufficientl}-  reduced  in  size 
to  enter  the  stenosed  portion  ;  b}'  alternating  the  direction 
of  the  pull  the  tube  is  drawn  out  by  its  free  ends  and  in  by 
the  silk  loop.  Increasing  sizes  of  tubes  can  be  employed, 
and  if  necessar}'  the  third  string  can  be  used  as  a  string-saw 
after  the  Abbe  plan  of  procedure.  This  operation  Avas  first 
successfully  performed  by  Dr.  A.  J.  Ochsner  of  Chicago." 
In  a  ver}'  severe  case  of  stenosis  gastrostomy  is  performed 
to  keep  the  patient  from  starving. 

Cancer  of  the  Esophagus. — This  disease  causes  obstruc- 
tion of  the  esophagus.  It  arises  in  those  beyond  middle  life, 
and  is  far  more  common  in  men  than  in  women.  The 
disease  may  arise  at  any  portion  of  the  gullet,  but  is  least 
often  met  with  in  the  central  portion  (Maylard,  Butlin). 
Epithelioma  is  the  usual  form,  but  scirrhus  or  encephaloid 
may  occur.  Cancer  soon  ulcerates,  involves  adjacent  parts, 
and  affects  the  deep  cervical  and  posterior  mediastinal 
glands. 

Syviptoins  of  Cancerous  Stcjiosis. — The  patient  is  over  fort}' 
years  of  age,  is  usually  a  male,  and  presents  the  same  diffi- 
culty of  swallowing  met  with  in  cicatricial  stenosis.  The 
vomited  matter  is  apt  to  contain  blood,  the  use  of  the  bougie 
causes  bleeding ;  there  are  generally  decided  pain  and  ver}' 
great  emaciation.  The  seat  of  obstruction  is  located  by 
the  bougie  and  by  listening  over  the  spine  while  the  patient 
is  attempting  to  swallow  water.  The  stomach  is  the  seat  of 
pain  ;  the  mouth  is  dry  and  there  is  often  great  thirst.    As  the 

^  Journal  A tnerican  Medical  Association,  July  29,   1S99. 


756   DISEASES  AND    INJURIES   OF  DIGESTIVE    TRACT. 

disease  infiltrates  the  involvement  of  adjacent  regions  pro- 
duces other  symptoms.  Dyspnea  may  result  from  tracheal 
pressure.     Plcuritis,  pericarditis,  or  pneumonia  may  arise. 

Treatment. — The  disease  is  of  necessity  fatal,  and  treatment 
is  only  palliative.  Successful  incision  is  not  feasible.  The 
patient  should  be  put  upon  a  soft,  bland  diet  in  small  quantities 
given  frequently.  When  trouble  is  experienced  even  with 
such  food  pass  a  bougie  every  third  or  fourth  day.  When 
the  patient  -becomes  entirely  unable  to  swallow  soft  food  we 
may  insert  a  Symonds  tube  or  do  an  esophagostomy  (if  this 
can  be  performed  below  the  stricture),  or  perform  gastros- 
tomy. In  every  doubtful  case  of  esophageal  stricture  give 
a  course  of  iodid  of  potassium  before  performing  any 
operation. 

Spasmodic  Stricture  of  the  Esophagus  (Esophagismus, 
Hysterical  Stricture). — By  this  term  is  meant  a  spasm  of  the 
circular  muscular  fibers  of  the  gullet,  which  is  most  com- 
mon at  one  end  of  the  tube.  This  condition  not  unusually 
arises  in  a  hysterical  individual,  in  which  case  it  will  be 
associated  with  the  stigmata  of  hysteria,  especially  globus 
hystericus.  In  some  cases  evidences  of  hysteria  are  wanting, 
although  the  patient  is  neurotic,  and  the  condition  is  due  to 
a  reflex  irritation.  It  has  arisen  in  cases  of  cancer  of  the 
stomach,  cancer  of  the  liver,  ulceration  of  the  larynx,  and 
during  pregnancy.  It  occasionally  occurs  in  tetanus,  always 
in  hydrophobia,  and  sometimes  in  epilepsy. 

Symptoms  of  Spasmodic  Stenosis. — It  arises  suddenly  in  a 
hysterical  or  neurotic  individual.  It  may  last  for  a  time  and 
suddenly  pass  away,  or  may  persist  for  a  long  time.  The 
difficulty  in  swallowing  is  irregular ;  sometimes  solids  are 
taken  more  readily  than  fluids,  and  vice  versa. 

There  may  be  regurgitation;  but  if  it  occurs,  it  does  so 
at  once  on  swallowing  food.  Examination  with  a  bougie 
detects  the  obstruction.  If  the  bougie  is  held  firmly  against 
it,  in  most  cases  the  spasm  will,  after  a  time,  relax  and  let 
the  instrument  pass.  A  medium-sized  instrument  or  a 
large  instrument  can  be  passed  more  easily  than  a  small  one. 
In  some  cases  no  instrument  can  be  passed  until  the  patient 
has  been  anesthetized,  but  in  every  case  a  bougie  can  be 
passed  after  an  anesthetic  has  been  given. 

Treatment. — The  systematic  passage  of  bougies.  Occa- 
sionally the  passage  of  an  instrument  but  once  will  cure  a 
case.  The  general  health  must  be  improved,  and  in  per- 
sistent cases  it  may  be  necessary  to  use  electricity  within  the 
esophagus,  employ  cold  locally,  and  administer  the  bromides. 


DISEASES    OF   THE   MOUTH,    ETC.  757 

Diverticula  of  the  Esophagus. — Maylard  tells  us  that 
these  pouches  may  be  due  to  one  of  four  causes — they  may 
be  congenital ;  may  be  due  to  stricture ;  may  be  caused  by 
pressure  from  within,  upon  a  weak  spot  of  the  wall ;  may 
be  due  to  traction  from  without,  by  the  healing  and  con- 
traction of  an  area  of  inflammation. 

Symptoms. — When  the  diverticulum  is  in  the  neck  a  lump 
forms  during  deglutition,  and  this  lump  may  be  obliterated  by 
pressure.  Food  will  pass  into  the  stomach  only  when  the 
diverticulum  is  full.  A  bougie  cannot  be  passed  unless  the 
pouch  is  full  of  food,  at  which  time  it  may  pass  or  may  not. 
This  latter  symptom,  the  variability  in  the  passage  of  the  bougie, 
is  the  evidence  relied  on  for  diagnosis  in  intrathoracic  diver- 
ticula. By  listening  with  a  stethoscope  fluid  may  be  heard 
to  pass  into  the  pouch.  After  a  patient  swallows  food  mixed 
with  subnitrate  of  bismuth  a  diverticulum  may  be  skiagraphed. 
Treatment. — Extirpation  and  suture,  as  performed  by  von 
Bergmann,  Hearn,  and  others. 

Injuries  of  the  Esophagus. — Injuries  of  the  internal  sur- 
face are  more  common  than  injuries  from  without.  Burns 
and  scalds  are  among  these  injuries.  Wounds  may  be  in- 
flicted by  foreign  bodies.  These  injuries  cause  pain  on  swal- 
lowing. A  severe  injury  causes  bleeding,  the  blood  being 
both  coughed  up  and  vomited.  A  severe  wound  may  involve 
a  large  vessel  and  cause  violent  or  fatal  hemorrhage.  If  the 
bronchus  or  trachea  is  involved,  there  will  be  "  cough  and 
expectoration  of  blood,  mucus,  and  food  "  (Maylard).  The 
pleural  or  pericardiac  sacs  may  be  perforated. 

Treatment. — Feed  only  by  the  rectum.  Give  morphin 
hypodermatically.  Do  not  feed  by  the  mouth  for  ten  days, 
and  even  then  give  only  fluid  food  and  jelly.  Symptoms  are 
met  as  they  arise.  After  burns  by  caustic,  administer  the  anti- 
dote ;  give  large  draughts  of  water  and  wash  out  the  stomach. 
From  two  to  four  weeks  after  a  caustic  has  been  swallowed 
and  after  a  burn  or  scald,  the  use  of  sounds  should  be  begun, 
and  sounding  should  be  persisted  in  for  a  considerable  time 
to  prevent  contraction. 

Injuries  of  the  Esophagus  from  Outside,  without  In- 
volvement of  Other  Structures. — Such  injuries  are  rare. 
Esophageal  injuries,  as  a  rule,  are  associated  with  serious 
damage  to  adjacent  structures.  These  injuries  may  be  due 
to  stabs  or  to  bullets.  Besides  the  obvious  external  signs 
of  the  injur}'  there  will  be  difficulty  in  swallowing,  cough, 
bloody  expectoration  or  vomiting ;  and  mucus  or  the  con- 
tents of  the  stomach  may  run  out  of  the  wound. 


758   DISEASES  AND   INJURIES   OF  DIGESTIVE    TRACT. 

Treatment. — Suture  the  wound,  and  feed  by  the  rectum  for 
ten  days. 

Foreign  Bodies  Lodged  in  the  Esophagus. — These  acci- 
dents occur  especially  to  children  and  lunatics,  and  women 
are  more  apt  to  suffer  from  them  than  are  men.  An  extended 
list  of  bodies  which  have  been  swallow^ed  will  be  found  in 
Poulet's  elaborate  treatise.  There  are  three  regions  where  a 
foreign  body  is  especially  apt  to  lodge — viz.  opposite  the 
cricoid  cartilage,  at  the  level  of  the  diaphragm,  and  at  the 
point  where  the  left  bronchus  crosses  the  gullet.  Small  and 
sharp  bodies  may  lodge  anywhere. 

Syviptovis. — The  symptoms  are  variable  ;  if  the  body  is 
large,  there  will  be  pain  and  difficulty  in  swallowing,  and,  in 
some  cases,  dyspnea  from  pressure  upon  the  trachea  or 
bronchus.  Death  may  result  from  asphyxia.  In  some  other 
cases  the  symptoms  are  very  slight.  If  the  body  is  sharp, 
there  will  be  hemorrhage  and  severe  pain.  The  blood  may 
be  hawked  up,  or  may  be  swallowed  and  vomited.  A  patient 
may  grow  accustomed  to  a  foreign  body  and  cease  to  notice 
it ;  but,  on  the  contrary,  the  foreign  body  may  produce  in- 
flammation, and  even  may  ulcerate  into  the  windpipe,  the 
pleura,  the  pericardium,  or  the  aorta.  In  many  cases  of  im- 
paction a  patient  makes  violent  efforts  to  hawk  it  up,  and 
produces  aphonia.  There  may  be  violent  retching.  Even 
after  a  foreign  body  has  been  removed  by  swallowing  or 
otherwise  a  sensation  is  apt  to  remain  as  if  it  were  still 
lodged.  The  diagnosis  is  made  by  the  history,  the  detection 
of  the  body  by  external  manipulation,  by  feeling  it  with  an 
esophageal  bougie,  and,  if  bone  or^etal,  seeing  it  with  the 
fluoroscope  or  obtaining  a  skiagraph. 

Treatment. — The  surgeon  should  find  out  if  possible  the 
size,  shape,  weight,  and  nature  of  the  foreign  body,  and  locate 
its  point  of  impaction.  The  exact  point  of  lodgement  of 
bone  or  a  metallic  body  is  determined  by  the  ;i'-rays.^  An 
anesthetic  is  usually  necessary  for  a  child,  a  nervous  woman, 
or  a  lunatic,  and  is  sometimes  necessary  for  a  man.  If  the  for- 
eign body  is  soft,  external  manipulation  may  succeed  in  alter- 
ing its  shape,  so  that  it  may  be  swallowed  or  ejected.  If  the 
foreign  body  is  hard,  external  manipulation  may  shift  its  posi- 
tion. It  is  usually  impossible  to  reach  the  foreign  body 
through  the  mouth  by  means  of  the  fingers  (when  the  body 
is  in  the  rear  of  the  pharynx  it  may  be  pulled  forward  or 
pushed  down).  Sharp  foreign  bodies  may  be  entangled  and 
carried  down  when  the  patient  eats  mush,  bread,  or  boiled 

^  See  cases  of  White,  Keen,  Alfred  Wood,  Maclntyre,  Taylor,  and  others. 


DISEASES    OF   THE   MOUTH,    ETC.  759 

potatoes.  The  administration  of  emetics  is  an  old  plan 
which  occasionally  succeeds,  but  which  is  too  unsafe  to  be 
employed.  Maylard  says  that  when  a  mass  of  food  is  im- 
pacted it  is  occasionally  possible  to  soften  and  disintegrate 
the  mass  by  administering  a  mixture  containing  pepsin.  The 
horsehair  probang  is  a  very  useful  instrument  (Fig.  267,  c). 
It  may  be  used  to  push  a  body  downward  into  the  stomach, 
or  to  catch  the  body  and  pull  it  up.  When  this  instrument 
is  withdrawn  it  opens  like  an  umbrella.  Morris  Richardson 
has  shown  that  in  an  adult  the  diaphragmatic  opening  is 
about  fourteen  and  one-half  inches  from  the  incisor  teeth,  a 
point  to  be  remembered  in  deciding  whether  to  push  down 
or  pull  up  the  impacted  article.  Esophageal  forceps  (Fig. 
267,  A,  b)  are  valuable  in  some  cases.  The  coin-catcher  (Fig. 
267,  d)  is  a  useful  instrument.  Crequy's  plan  of  removal  is 
to  take  a  tangled  mass  of  threads,  tie  a  stout  piece  of  string 
about  the  middle  of  it,  coat  it  with  sugar,  and  have  the  patient 
swallow  it.  It  may  pass  the  foreign  body ;  if  it  does  so,  on 
withdrawal  it  may  entangle  the  object  and  extract  it.  To 
remove  a  fish-hook  with  line  attached,  the  following  plan 
may  prove  successful :  stick  the  line  into  a  metal  catheter, 
carry  the  catheter  down  to  the  hook,  and  push  the  hook 
out.  It  is  not  proper  to  allow  a  foreign  body  to  remain  in 
the  esophagus  until  it  causes  ulceration.  Neither  is  it  proper 
to  make  prolonged  efforts  to  extract  it  through  the  mouth. 
Such  efforts  may  do  great  harm,  and  if  one  careful  and  con- 
sistent effort  fails  an  operation  should  be  performed.  If  the 
body  is  lodged  anywhere  above  the  lower  third  of  the  esoph- 
agus, external  esophagotomy  is  performed,  and  usually  on 
the  left  side.  Through  this  wound  the  foreign  body  is  extracted. 
The  cut  is  made  on  the  left  side,  between  the  trachea  and 
larynx  in  front  and  the  carotid  sheath  behind,  the  center  of 
the  incision  being  opposite  the  cricoid  cartilage.  After  the 
foreign  body  is  extracted  the  mucous  membrane  is  sutured 
with  chromic  catgut,  and  the  superficial  structures  are  closed 
with  silkworm-gut  after  a  drainage-tube  has  been  inserted. 
The  patient  is  fed  by  the  rectum  for  eight  or  ten  days. 
When  a  foreign  body  is  lodged  in  the  lower  portion  of  the 
tube,  the  stomach  is  opened  and  the  body  extracted  by  this 
route  (Morris  Richardson).  In  White's  case  of  jackstone 
in  the  gullet  gastrotomy  was  performed.  A  string  was  tied 
about  some  rolls  of  gauze,  the  string  was  passed  by  means 
of  a  whalebone  from  the  stomach  into  the  mouth,  and  the 
body  was  entangled  and  drawn  out. 


76o      DISEASES  AND   INJURIES   OF   THE  ABDOMEN. 


XXVII.  DISEASES  AND  INJURIES  OF  THE  ABDOMEN. 

Contusion  of  the  Abdominal  Wall  without  Injury 
of  Viscera. — In  some  cases  of  contusion  of  the  abdominal 
wall  only  the  parietes  are  damaged  ;  in  other  cases  the  viscera 
or  the  abdominal  tissues  are  injured.  Contusion  may  involve 
the  skin  alone,  or  may  involve  the  skin,  muscles,  and  perito- 
neum. In  simple  contusion  there  is  considerable  shock  if  the 
injury  is  severe.  There  is  pain,  increased  by  respiration, 
motion,  pressure,  and  attempts  at  urination  or  defecation. 
When  tenderness  appears  some  days  after  the  accident  there 
is  usually  deep-seated  injury.  Extensive  ecchymosis  may 
appear.  Even  after  a  severe  contusing  force  has  been  applied 
there  may  be  no  discoloration,  and  it  may  happen  that  after  a 
slight  force  there  is  much  discoloration.  There  is  great  ecchy- 
mosis in  anemic  persons,  victims  of  hemiplegia,  in  obese 
individuals,  opium-eaters,  and  drunkards.  In  severe  cases  the 
tissues  are  pulpefied  and  sloughing  inevitably  ensues.  Ab- 
scess occasionally  follows  contusion.  The  prognosis  after 
abdominal  contusion  is  always  uncertain. 

Treatment  of  Simple  Contusion. — In  treating  simple  con- 
tusion place  the  patient  at  rest  in  a  supine  position,  with  the 
thighs  flexed  over  a  pillow ;  obtain  reaction  from  the  shock. 
Give  morphin  if  pain  is  severe.  After  shock  has  passed  off 
it  is  advisable  to  place  an  ice-bag  over  the  seat  of  injury. 
If  much  blood  is  extravasated,  aspirate  and  apply  a  binder. 
After  twenty-four  hours  apply  local  heat  by  means  of  the  hot- 
water  bag,  employ  an  ointment  of  ichthyol,  and  move  the 
bowels,  if  necessary,  by  salines.  Regard  every  contusion  as 
serious,  and  watch  carefully  for  the  development  of  signs  of 
internal  hemorrhage  or  visceral  injury.  ' 

Muscular  Rupture  from  Contusion. — In  this  injury  there 
are  severe  shock  and  pain  (increased  by  respiration  and  move- 
ment). Separation  between  the  fibers  of  the  muscle  is  dis- 
tinct at  first,  but  it  is  soon  masked  by  effusion  of  blood. 
Such  injuries  may  cause  death,  or  may  lead  to  hernia.  The 
rectus  is  the  muscle  most  apt  to  rupture.  The  rupture  is  due 
to  sudden  contraction  rather  than  to  the  direct  effect  of  a  blow. 

The  treatment  is  the  same  as  for  simple  contusion.  Al- 
ways apply  a  binder.  A  hernia  is  returned  and  a  compress 
is  applied  over  the  opening  through  which  it  emerged.  If 
strangulation  occurs,  operate  at  once. 

Injuries  with  Damage  to  the  Peritoneum  or  the 
Viscera. — Rupture  of  the  Peritoneum. — The  peritoneum 


RUPTURE    OF  THE   STOMACH.  76 1 

may  be  involved  in  an  abdominal  contusion.  It  may  rupt- 
ure even  when  there  is  no  visceral  injury  or  muscular  contu- 
sion. The  uterine  peritoneum,  the  parietal  peritoneum,  the 
visceral  peritoneum,  or  the  mesentery  may  rupture.  Rupture 
of  the  peritoneum  causes  intra-abdominal  hemorrhage. 

The  ti'catuioit  consists  in  opening  the  abdomen,  arresting 
the  hemorrhage,  and  bringing  about  reaction. 

An  injury  to  the  peritoneum  creates  a  point  of  least  re- 
sistance, and  at  such  a  point  peritonitis  may  develop.  The 
peritonitis  is  usually  local,  but  may  become  general.  After 
any  severe  intra-abdominal  injury  the  symptoms  of  perito- 
neal shock  appear  (peritonism),  and  the  patient  may  rapidly 
die.  In  the  condition  of  peritonism  the  temperature  is  sub- 
normal;  the  extremities  are  cold;  the  face  is  pallid  and 
sunken ;  the  pulse  is  small,  weak,  and  very  frequent ;  the 
respiration  is  shallow  and  sighing ;  there  is  great  thirst ;  the 
patient  is  restless  and  tosses  about.  Vomiting  almost  always 
occurs.  In  some  cases  there  is  regurgitation  rather  than 
vomiting.  The  abdomen  is  the  seat  of  a  violent,  persistent 
pain.  The  patient  is  fearful  of  impending  death.  As  the 
symptoms  develop  in  a  grave  case  they  will  point  to  one  of 
two  conditions,  hemorrhage  or  peritonitis. 

In  intra-abdominal  hemorrhage  the  subnormal  temperature 
and  other  evidences  of  shock  persist.  Vomiting  ceases,  but 
nausea  exists.  The  patient  is  uncontrollably  restless  and  tosses 
about  in  bed.  The  thirst  is  great.  The  abdomen  is  not  rigid. 
Fainting-spells  occur.  Blood-examination  shows  a  marked 
fall  in  the  percentage  of  hemoglobin.  Percussion  demonstrates 
the  existence  of  an  effusion  which  alters  its  position  as  the 
patient's  position  is  altered,  and  which  gradually  increases 
in  amount.  Dulness  is  first  met  with  in  the  loins.  Rectal 
or  vaginal  examination  may  aid  in  diagnosis.  If  peritonitis 
develops,  the  vomiting  becomes  worse,  the  pain  intensifies, 
and  the  abdomen  grows  rigid  and  distended. 

Rupture  of  the  Stomach  without  External  Wound. 
— The  usual  cause  of  rupture  is  a  violent  blow,  although  the 
accident  may  happen  in  washing  out  the  stomach.  Rupture 
is  more  apt  to  occur  when  the  stomach  is  distended  with  food 
than  when  it  is  empty.  The  rupture  may  be  partial,  the  perito- 
neal coat  not  being  torn.  The  rupture  may  be  complete.  The 
region  of  the  pylorus  is  most  apt  to  be  lacerated.  The  symp- 
toms of  rupture  are  collapse,  severe  pain  over  the  entire  abdo- 
men, great  thirst,  excessive  tenderness,  especially  over  the  epi- 
gastric region,  occasionally  vomiting,  the  vomited  matter  being 
usually,  but  not  invariably,  bloody;  tympanitic  distention  and 


762      DISEASES  A. YD   INJURIES   OF   THE  ABDOMEN. 

muscular  rigidity  coming  on  after  a  few  hours.  Gas  may  enter 
the  abdominal  cavity  and  cause  the  disappearance  of  liver-dul- 
ness,  but  the  area  of  liver-dulness  can  be  lessened  by  great  in- 
testinal distention.  After  iiicoviplctc  rupture  local  peritonitis 
is  frequent;  in  complete  rupture  the  escape  of  food  into  the 
peritoneal  cavity  causes  general  peritonitis.  To  diagnosticate 
between  complete  and  incomplete  rupture,  endeavor  to  dis- 
tend the  viscus  with  hydrogen  gas  :  in  incomplete  rupture  the 
contour  of  the  dilated  stomach  can  be  made  out  upon  the 
surface ;  in  complete  rupture  the  viscus  cannot  be  distended, 
and  the  gas  passes  into  the  peritoneal  cavity,  producing  the 
physical  signs  of  tympanites  (Senn). 

The  trcatincnt  in  complete  rupture  is  as  follows :  if- 
signs  of  hemorrhage  are  absent,  endeavor  to  bring  about 
reaction  before  operating.  If  these  signs  are  present,  operate 
at  once,  and  have  salt  solution  infused  into  a  vein  during  the 
operation.  Open  the  abdomen.  If  the  seat  of  rupture  is  not 
visible,  it  may  be  found  by  inflating  the  stomach  with  hydrogen. 
Flush  out  the  stomach  and  the  peritoneal  cavity  with  hot  salt- 
solution  ;  sew  up  the  stomach-wound  with  a  double  row  of  silk 
sutures,  the  first  row  being  buried  and  including  the  muscular 
coat  and  mucous  coat,  the  second  row  being  Halsted  sutures; 
drain;  close  the  wound  in  the  parietes  with  silkworm-gut; 
feed  by  the  rectum  for  four  days,  and  then  begin  the  admin- 
istration of  a  very  little  food  by  the  mouth.  In  incomplete 
rupture  the  danger  is  perforation.  The  patient  is  put  to  bed, 
and  after  reaction  has  taken  place,  is  fed  by  the  rectum  for 
several  days,  and  morphin  is  given  hypodermatically. 

Rupture  of  the  Intestine  without  [External  Wound. 
— The  symptoms  of  this  injury  are  profound  shock,  tympan- 
ites, and  pain,  rapidly  followed  by  peritonitis  if  the  patient 
survives.  Vomiting  comes  on  soon  after  the  accident,  the 
vomited  matters  being  possibly  at  first  bloody  and  later 
stercoraceous.  The  respiration  is  thoracic,  the  tongue  is 
dry,  and  great  thirst  exists.  The  pulse,  which  is  slow  at 
first,  becomes  small  and  rapid  and  of  high  tension. 
Any  portion  of  the  intestine  may  rupture,  but  the  ileum  is 
most  liable  to  this  accident.  Blood  in  the  stools  rarely 
appears  early  enough  to  be  of  diagnostic  value.  The  escape 
of  gas  into  the  peritoneal  cavity  may  cause  the  diminution 
or  disappearance  of  liver-dulness.  After  anesthetizing  the 
patient  hydrogen  gas  insufflated  into  the  rectum  will  come 
from  the  mouth  if  there  is  no  perforation  in  the  stomach  or 
the  intestine;  if  a  perforation  exists,  tympanites  is  much 
increased,    and   the    area    of  liver-dulness    disappears.      To 


RUPTURE    OF   THE   INTESTINE.  763 

apply  rectal  insufflation  of  hydrogen,  generate  the  gas  in  a 
bottle  by  means  of  zinc  and  sulphuric  acid,  catch  the  gas  in 
a  large  rubber  bag,  and  attach  the  tube  from  the  gas  reser- 
voir to  a  tip  which  is  inserted  in  the  rectum.  Give  the  patient 
ether  to  relax  the  abdominal  muscles,  direct  an  assistant  to 
press  the  anal  margins  against  the  rectal  tip,  and  when  the 
patient  is  unconscious  turn  on  the  stopcock  and  press  upon 
the  reservoir  (Senn). 

It  has  been  suggested  that  ether  vapor,  mixed  with  air, 
can  be  used  instead  of  hydrogen  gas.'  In  this  method  a 
little  ether  is  poured  into  the  bottle  of  an  aspirator,  the 
valves  are  opened,  one  tube  is  carried  into  the  rectum,  the 
other  tube  is  attached  to  a  bicycle-pump,  and  by  working 
the  pump  the  ether  vapor  is  driven  into  the  bowel.  If  there 
is  perforation,  tympanites  is  notably  increased.  Some  sur- 
geons regard  the  rectal  insufflation  test  as  unsatisfactory 
and  often  dangerous. 

Treatment  of  Rupture  of  Intestine. — If  symptoms  point 
to  dangerous  hemorrhage,  operate  at  once ;  otherwise  do  not 
operate  until  reaction  has  been  obtained.  Wrap  the  patient 
in  blankets,  surround  him  with  hot  cans,  give  hot  stimulating 
enemata,  give  stimulants  by  the  rectum,  and  a  hypodermatic 
injection  of  morphin  and  atropin;  infuse  hot  saline  fluid  into 
a  vein ;  asepticize  and  anesthetize.  Perform  a  laparotomy ; 
check  hemorrhage ;  find  the  rent,  and  close  it  by  Halsted 
sutures  if  possible.  The  hydrogen  gas  test  of  Senn  will 
locate  a  perforation.  It  may  be  necessary  to  perform  an 
end-to-end  approximation  or  a  lateral  anastomosis.  Flush 
the  abdominal  cavity  with  hot  saline  solution,  and  wipe  the 
peritoneal  fossae  and  the  space  between  the  liver  and  dia- 
phragm with  gauze.  Finney  eviscerates,  wipes  out  the  ab- 
dominal cavity,  and  wipes  the  intestines  as  he  restores 
them.  Whatever  method  is  used  to  cleanse  the  abdomen, 
remember  that  infectious  material  is  apt  to  accumulate 
between  the  liver  and  diaphragm  and  in  Douglas's  pouch. 
Drainage  is  to  be  used. 

"In  abdominal  operations  it  is  frequently  imperatively 
necessary  that  the  large  intestine  be  recognized  with  cer- 
tainty or  the  small  bowel  be  positively  identified.  The  size 
of  the  tube  will  not  always  aid  in  this  recognition,  as  a  small 
intestine  may  be  distended  enormously  and  a  large  intestine 
may  be  contracted  to  the  size  of  a  finger  because  of  obstruc- 
tion above.  The  longitudinal  muscular  fibers  of  the  large 
bowel  are  accentuated  in  three  portions  ;  these  accentuations 

1  Emerson  M.  Sutton  of  Geneva,  \n  Jour.  Am.  Med.  Assoc,  July  23,  1898. 


764      DISEASES  AND  INJURIES   OF  THE  ABDOMEN. 

constitute  the  three  longitudinal  bands  which  begin  at  the 
cecum  and  terminate  at  the  end  of  the  sigmoid  flexure  of 
the  colon.  Each  band  is  composed  of  a  number  of  shorter 
bands,  the  shortness  of  these  constituent  bands  permitting 
the  sacculation  of  the  large  intestine.  Longitudinal  bands 
and  sacculation  are  not  met  with  in  the  small  gut,  their 
presence  or  absence  being  a  means  of  identification  in  many- 
cases  ;  but  when  the  colon  is  much  distended  the  bands 
cannot  be  seen  distinctly  and  the  sacculation  disappears. 
From  the  large  intestine  only  spring  the  appendices  epiplo- 
icae  (small  overgrowths  of  fat  in  pouches  of  peritoneum),  but 
they  are  sometimes  not  well  marked  except  upon  the  trans- 
verse colon,  and  when  emaciation  exists  they  may  almost 
entirely  disappear.  The  relatively  fixed  position  of  the 
large  intestine  and  the  free  mobility  of  the  small  bowel  are 
important  points  of  distinction.  The  foregoing  indicates  that 
it  is  not  always  easy  to  distinguish  between  colon  and  small 
gut,  and  that,  according  to  old  rules,  it  may  be  often  neces- 
sary to  make  large  incisions,  to  see  as  well  as  feel,  and  to 
handle  a  large  extent  of  the  bowel.  Any  scrap  of  knowl- 
edge that  will  shorten  an  abdominal  operation,  that  will  per- 
mit of  as  certain  work  through  a  smaller  incision,  and  that 
will  diminish  handling  of  intraperitoneal  structures,  tends  to 
increase  the  chances  of  recovery.  For  these  reasons  the 
writer  suggests  a  method  of  bowel-identification  which  rests 
upon  the  facts  that  each  bowel  has  a  posterior  attachment, 
that  the  origin  of  the  attachment  differs  according  to  the 
bowel  it  supports,  that  a  single  finger  can  detect  the  origin 
of  the  peritoneal  support  of  any  section  of  the  bowel,  and, 
this  origin  being  known,  the  portion  of  the  bowel  it  supports 
is  with  certainty  deducible.  In  an  exploratory  operation,  for 
instance,  the  finger  comes  in  contact  with  the  bowel :  to  de- 
termine whether  it  is  a  large  or  a  small  bowel,  note  first  if 
the  structure  is  movable  or  is  firmly  fixed ;  next,  pass  the 
finger  over  the  bowel  and  let  it  find  its  way  posteriorly.  If 
dealing  with  a  small  bowel,  the  finger  will  reach  the  origin 
of  the  mesentery  between  the  left  side  of  the  second  lumbar 
vertebra  and  the  right  sacro-iliac  joint ;  if  dealing  with  the 
large  bowel,  the  finger  will  reach  the  origin  of  the.  meso- 
colon, or  the  point  where  the  colon  is  fixed  posteriorly  and 
to  the  side."^ 

Rupture  of  the  liver  may  be  caused  by  a  blow,  a  fall 
from  a  height,  or  the  concussion  of  a  railroad  collision.  Occa- 
sionally the  ends  of  fractured  ribs  are  driven  into  the  organ. 

1  The  author,  in  Medical  News,  June  9,  1894. 


IVOiW'DS   OF   THE   ABDOMIXAL    WALL.  765 

The  symptoms  are  those  previously  set  forth  as  attending 
severe  intra-abdominal  injury  (p.  761).  In  addition  there 
are  tenderness  over  the  hver,  and  often  pain  in  the  abdomen 
and  back.  As  a  rule,  the  signs  of  hemorrhage  are  present. 
Sugar  may  appear  in  the  urine.  The  respiration  is  much 
embarrassed.  After  a  few  days  the  skin  may  itch  and  become 
jaundiced,  but  this  is  rare. 

In  these  cases  operate  at  once  if  hemorrhage  is  se\'ere ; 
otherwise  operate  after  bringing  about  reaction.  Stop  bleed- 
ing in  the  liver  by  cauter}-,  by  suture,  or  by  packing.  In  a 
superficial  tear  introduce  sutures  of  catgut  or  silk.  In  a  deep 
tear  suture  the  liver  to  the  belly-wall,  pack  the  wound  with 
gauze,  and  surround  it  with  gauze. 

Rupture  of  the  Gall-bladder  and  the  Bile-ducts.— 
Rupture  of  the  gall-bladder  or  the  ducts  is  most  apt  to 
happen  from  injury  when  gall-stones  exist.  Peritonitis, 
general  or  local,  is  almost  certain  to  follow  such  a  rupture. 
Besides  those  symptoms  common  to  all  severe  abdominal 
injuries,  there  is  often  intense  jaundice. 

Treatment. — Suture  the  laceration  or  make  a  biliary 
fistula. 

Rupture  of  the  Spleen. — The  spleen  may  be  dislocated 
as  well  as  ruptured.  Rupture  of  the  spleen  is  rare  without 
other  serious  injuries.  An  enlarged  spleen  is  far  more  liable 
to  iniun,'  than  a  normal  organ.  The  usual  symptoms  of 
abdominal  injury  are  present.  In  addition  there  are  pain 
over  the  spleen  and  heart,  tenderness  over  the  spleen,  and 
great  shortness  of  breath.  Hemorrhage  is  generally  profuse 
but  slow.  The  splenic  blood  contains  numerous  leukocytes 
and  clots  rapidly,  hence  the  bleeding  is  usually  arrested  for 
a  time,  and  a  patient  does  not  often  bleed  to  death  rapidly 
(Ballance). 

Ballance  points  out  that  dulness  is  found  in  the  left  loin, 
but,  because  of  the  clotting  of  the  blood,  the  dulness  does 
not  shift,  as  it  does  in  bleeding  from  other  intraperitoneal 
structures,  when  the  position  of  the  patient  is  shifted. 

Treatment. — Ballance  tells  us  that  after  a  splenic  injury 
there  is  shock,  but  after  a  time  there  is  a  distinct  reaction. 
Wait  for  the  reaction,  and  when  it  occurs  remove  the  spleen. 
Rupture  of  the  Kidney  (page  950). 
Rupture  of  the  Ureter  (page  952). 
Wounds  of  the  Abdominal  Wall. — Non-penetrating- 
womids  are  to  be  treated  on  general  principles.     They  are 
sutured  with  great  care  and  are  firmly  supported  externally. 
Ventral  hernia  may  follow  a  large  wound. 


766      DISEASES  AND   INJURIES   OE   THE  ABDOMEN. 

Penetrating  "Wounds. — The  sj'inptojns  of  penetrating 
wounds  of  the  abdominal  wall  are  usually  those  of  shock 
and  hemorrhage,  and  later  of  septic  peritonitis.  Emphysema 
is  apt  to  occur  and  viscera  may  protrude,  and  often  do  in  the 
case  of  a  large  incised  or  lacerated  wound.  Extravasation  of 
contents  of  intra-abdominal  viscera  is  very  apt  to  occur,  and 
is  sure  to  occur  if  the  viscus  was  distended  when  injured. 
Normal  urine  and  normal  bile  may  do  little  harm,  but  if  either 
excretion  is  septic  disastrous  consequences  are  certain  to  en- 
sue. If  intestinal  contents  escape,  septic  peritonitis  is  certain 
to  occur.  Bleeding  is  usually  profuse  and  prolonged,  because 
spontaneous  arrest  of  hemorrhage  from  any  considerable 
vessel  will  rarely  take  place  within  the  abdomen. 

Treatment. — The  surgeon  endeavors  to  discover  promptly 
if  a  wound  of  the  abdominal  wall  is  or  is  not  penetrating  in 
character.  This  fact  may  be  proved  by  protrusion  of  viscera, 
by  the  appearance  of  stomach-contents  in  the  wound,  or  by 
a  flow  of  bile,  urine,  or  feces  from  the  wound.  If  none  of 
the  above  indications  exist,  and  if  there  are  no  signs  of 
serious  hemorrhage,  the  wound  should  be  irrigated  with  hot 
salt  solution,  and  should  be  dressed  with  gauze,  and  every 
effort  should  be  made  to  bring  about  reaction. 

When  reaction  is  obtained  the  wound  should  be  enlarged 
layer  by  layer  until  it  becomes  obvious  whether  the  peri- 
toneum is  open  or  not.  Madelung  of  Strassburg  points  out 
that  incision  layer  by  layer  will  be  of  no  use  in  settling  the 
question  of  penetration  if  the  wound  is  in  the  chest,  the 
buttock,  the  perineum,  or  the  back  of  a  fat  individual.^  If 
after  incision  layer  by  layer  it  becomes  evident  that  penetra- 
tion has  not  occurred,  the  wound  should  be  closed  and 
treated  on  general  principles.  If  it  becomes  evident  that  it 
has  occurred,  the  abdomen  should  be  opened  at  the  point  of 
penetration,  and  a  thorough  exploration  of  intra-abdominal 
structures  should  be  made  in  order  to  determine  the  injury 
and  be  able  to  treat  it  properly. 

In  a  case  still  doubtful  after  incision  layer  by  layer,  do  an 
exploratory  laparotomy  in  the  middle  line. 

In  every  case  in  which  it  is  evident  that  penetration  has 
occurred  laparotomy  is  necessary  in  order  to  detect  and 
correct  intra-abdominal  injury,  and  clean  the  peritoneum  by 
flushing  with  hot  salt  solution.  If  viscera  protrude,  they 
must  be  washed  off  with  hot  salt  solution  and  covered  with 
hot  sterile  pads,  and  after  the  patient  has  reacted  the  wound 
should  be  enlarged,  the  contents  of  the  abdomen  investi- 

^  Amials  of  Surgery,  September,  1897. 


irOiWDS    OF   THE   ABDOMINAL    JVALL.  767 

gated,  hemorrhage  arrested,  wounds  properly  treated,  and 
the  viscera  returned. 

It  is  customary  to  flush  the  belly  with  hot  salt  solution, 
some  of  the  fluid  being  allowed  to  remain.  This  proceeding 
mechanically  cleanses  the  peritoneum,  removes  blood-clots, 
and  strongly  combats  shock.  It  is  not  absolutely  necessary 
to  flush  out  the  belly  unless  a  considerable  hemorrhage  has 
occurred,  or  feces  or  stomach-contents  have  been  extrav- 
asated.  If  extravasation  of  stomach-contents  or  feces  has 
occurred,  not  only  should  flushing  be  practised,  but  eviscera- 
tion should  be  carried  out ;  the  fouled  intestine  should  be 
wiped  off  with  gauze  pads  wet  with  hot  salt  solution,  and  be 
wrapped  in  hot  moist  towels;  the  peritoneal  fossae  should 
be  rubbed  with  gauze  pads  and  the  space  between  the  liver 
and  diaphragm  should  be  carefully  wiped. 

A  wound  of  the  stomach  may  be  sutured ;  a  wound  of  the 
bowel  may  be  sutured  or  resection  and  anastomosis  or 
resection  and  end-to-end  suturing  may  be  required.  Visceral 
injuries  are  treated  by  appropriate  means.  In  a  punctured 
Avound  or  a  gunshot-wound  of  the  intestine,  rectal  insuffla- 
tion of  hydrogen  gas  may  disclose  the  nature  of  the  injury, 
but  evisceration  may  be  required. 

After  the  completion  of  intra-abdominal  manipulations  the 
surgeon  restores  an}-  protruding  bowel. 

Drainage  is  required  when  the  contents  of  the  stomach  or 
the  intestines  have  escaped,  when  hemorrhage  is  severe,  or 
when  the  Hver,  pancreas,  kidney,  or  spleen  is  found  to  be 
damaged.  The  peritoneum  may  be  sutured  with  a  continuous 
suture  of  catgut,  and  the  muscles,  fascia,  and  skin  with 
interrupted  sutures  of  silkworm-gut,  or  through-and-through 
sutures  of  silkworm-gut  ma\-  be  used.  Active  stimula- 
tion and  artificial  heat  are  needed  immediatel}'  after  the  oper- 
ation to  combat  shock.  In  many  cases  intravenous  infusion 
of  hot  normal  salt  solution  is  of  great  value.  It  may  be 
given  both  during  and  after  operation.  Enteroclysis,  or  high 
rectal  injection  of  hot  saline  fluid,  is  useful.  So  is  hypodermo- 
clysis,  or  the  subcutaneous  injection  of  hot  salt  solution.  The 
after-treatment  consists  of  rest,  avoidance  of  food  b}-  the 
stomach  for  forty-eight  hours,  and  the  administration  of 
brandy  and  water  from  time  to  time.  For  two  da}-s  the  pa- 
tient should  be  fed  b\'  the  rectum.  On  the  appearance  of 
the  first  sign  of  peritonitis,  forty-eight  hours  or  more  after 
the  operation,  give  a  saline  cathartic.  It  is  not  wise  to  purge 
during  the  first  forty-eight  hours  after  the  operation.  When 
there  is  no  sign  of  peritonitis,  a  purge  should  not  be  given 


768      DISEASES  AND   INJURIES   OF   THE  ABDOMEN. 

until  the  fourth  day.  After  forty-eight  hours  hquid  food  can 
usually  be  given  by  the  stomach.  Solid  food  may  be  given 
after  seven  or  eight  days,  but  the  patient  must  not  leave  his 
bed  until  the  wound  is  firmly  united,  because  of  the  danger  of 
ventral  hernia.  A  support  should  be  worn  for  a  long  time. 
Gunshot-wounds  of  the  Abdomen. — If  a  bullet  has 
penetrated,  it  may  or  it  may  not  have  produced  visceral 
damage.  A  pistol-bullet  or  the  bullet  of  a  sporting-rifle 
usually  does ;  a  projectile  of  a  modern  military  rifle  may 
not  or  may  produce  wounds  which  can  be  recovered  from 
without  operation.  If  symptoms  of  hemorrhage  exist,  in 
either  military  or  civil  practice,  the  abdomen  should  be 
opened  in  the  midline,  the  source  of  hemorrhage  should  be 
found  and  the  bleeding  should  be  arrested,  and  a  search 
should  be  made  for  visceral  injuries.  The  hydrogen  gas 
test  is  of  value  in  locating  an  intestinal  perforation.  If  the 
ether-test  of  Sutton  is  used,  the  odor  of  the  drug  is  detected 
as  the  vapor  emerges  from  a  perforation.  No  prolonged 
search  for  the  bullet  is  permissible.  In  civil  practice,  lapar- 
otomy should  be  performed  for  a  penetrating  gunshot-wound 
of  the  abdomen.  In  military  practice  this  rule  cannot  always 
be  carried  out.  In  fact,  it  has  been  proved  that  the  modern 
small  bullet  may  perforate  the  abdomen,  and  yet  recovery 
may  follow  with  a  singular  absence  of  serious  symptoms. 

Stomach    and  Intestines. 

Foreign  Bodies  in  the  Alimentary  Canal. — Foreign 
bodies  of  considerable  size  are  rarely  taken  into  the  aliment- 
ary canal  except  by  children,  insane  people,  or  drunkards. 
Most  foreign  bodies  swallowed  are  passed  with  the  feces,  but 
some  lodge.  Any  body  which  can  pass  the  esophagus  is 
not  too  large  to  pass  through  the  intestines.  A  foreign  body 
may  lodge  in  the  stomach.  In  some  cases  there  are  no 
symptoms.  In  other  cases  symptoms  are  violent.  The 
severity  of  the  symptoms  depends  upon  the  shape  and  char- 
acter of  the  body. 

In  some  cases  it  is  possible  to  feel  "the  body  from  without. 
A  metal  body  in  the  stomach  will  deflect  a  magnetic  needle 
held  over  the  viscus  (Polaillon).  Many  foreign  bodies  can 
be  skiagraphed.  It  is  not  wise  to  attempt  to  recover  the 
body  by  inducing  vomiting.  In  some  cases  gastrotomy  is 
necessary.  When  a  foreign  body  has  been  swallowed  the 
usual  treatment  is  as  follows  :  a  purgative  should  never  be 
given  to  expedite  the   passage   of  a  foreign  body,  because 


CARCINOMA    OF   THE   STOMACH.  769 

increased  peristalsis  means  increased  danger  of  impaction  or 
of  perforation.  Endeavor  to  encrust  the  foreign  body,  and 
thus  lessen  the  danger  of  perforation,  by  feeding  with  bread 
and  milk  only  for  several  days,  and  at  the  end  of  this  period 
give  a  mild  laxative.  An  exclusive  diet  of  mush  or  of 
mashed  potatoes  has  been  suggested.  Pain  is  relieved  by 
opium.  A  foreign  body  rarely  lodges  in  the  duodenum,  but 
may  lodge  lower  down,  and  may  cause  ulcei'ation,  perforation, 
abscess,  or  intestinal  obstruction.  Operation  may  be.  neces- 
sary in  such  cases. 

Carcinoma  of  the  Stomach. — Innocent  tumors  and 
sarcomata  occasionally  attack  the  stomach,  but  they  are  in- 
finitely rare  in  comparison  Avith  primary  cancer.  This  disease 
is  unusual  before  the  age  of  forty.  It  is  more  common  in  men 
than  in  women.  In  a  very  few  instances  cancer  has  been 
found  to  have  arisen  from  an  ulcer.  The  forms  of  cancer 
met  with,  set  forth  in  their  order  of  frequency,  are,  according 
to  Osier,  epithelioma,  encephaloid,scirrhus,  and  colloid.  Can- 
cer may  be  limited  to  the  body  of  the  stomach  (either  curv- 
ature or  either  wall),  the  pyloric  end,  or  the  cardiac  end;  but 
it  may  involve  two  of  these  regions,  or  almost  the  entire 
stomach,  or,  being  multiple,  may  be  found  in  many  parts.  It 
is  usually  fatal  in  from  four  months  to  two  years. 

Symptoms. — The  disease  comes  on  gradually,  usually 
with  indigestion  and  physical  weakness.  The  patient  has 
persistent  dragging  pain,  which  is  increased  by  eating  and 
pressure,  and  attacks  of  vomiting  are  frequent.  After  a 
short  time  the  patient  becomes  very  weak  and  excessively 
anemic,  and  it  is  often  possible  to  feel  a  tumor  in  the  stomach. 
Blood  examination  shows  diminution  of  red  corpuscles  and 
hemoglobin,  and  absence  of  any  increase  of  leukocytes  after 
a  full  meal.  The  vomiting  of  gastric  cancer  is  at  first  only 
occasional,  but  as  the  case  progresses  it  becomes  more  and 
more  frequent.  Vomiting  soon  after  eating  occurs  when  the 
cardiac  region  is  involved ;  vomiting  an  hour  or  so  after  eating 
occurs  when  the  pyloric  end  is  involved.  When  the  body 
of  the  organ  is  the  seat  of  disease,  vomiting  may  be  absent. 
The  vomited  matter  is  often  mixed  with  a  small  amount  of 
altered  blood  (coffee-ground  vomit).  In  most  cases  free 
hydrochloric  acid  is  not  found  in  the  stomach,  but  lactic  acid 
is  found  and  Oppler's  bacillus  can  often  be  detected.  Exam- 
ine with  care  a  patient  in  whom  cancer  is  suspected. 

Distend  the  stomach  with  gas  or  fluid  and  map  out  its 
outlines.     Feel  for  a  tumor.     A  tumor  can  usually  be  felt  if 
it  involves  the  greater  curvature,  or  anterior  wall,  and  a  large 
49 


770      DISEASES  AND   INJURIES    OF   THE   ABDOMEN. 

tumor  of  the  pylorus  can  be  palpated,  but  in  other  regions 
the  tumor  can  rarely  be  felt.  Give  a  test-meal,  siphon  off  the 
contents  of  the  stomach,  and  examine  for  free  hydrochloric 
acid,  lactic  acid,  and  Oppler's  bacilli.  Ewald's  test-breakfast 
is  usually  employed.  It  consists  of  a  dry  roll  and  three- 
fourths  of  a  pint  of  weak  tea  or  warm  water.  It  is  given  on 
an  empty  stomach.  After  an  hour  the  stomach-tube  is  intro- 
duced. The  fluid  is  removed  by  a  pump  or  by  abdominal 
compression. 

Cancer  of  the  cardiac  end  interferes  with  the  entrance  of 
food  into  the  stomach,  and  in  such  a  case  the  stomach  is 
shrunken  and  the  esophagus  is  dilated  immediately  above 
the  growth.  In  cancer  of  the  pylorus  the  food  is  partially 
or  completely  arrested  as  it  passes  to  emerge  from  the 
stomach,  and  the  stomach  becomes  much  dilated.  The 
vomited  matter  in  a  case  of  cancer  rarely  contains  recog- 
nizable fragments  of  the  growth,  but  fluid  with  which  the 
stomach  has  been  irrigated  may  contain  pieces  which  can  be 
identified  as  cancer  (Rosenbach). 

In  cancer  of  the  stomach  the  general  course  of  the  tem- 
perature is  normal,  but  there  are  occasional  deviations  to 
below  or  above  normal.  In  many  cases  the  urine  contains 
albumin,  indican,  acetone,  and  casts.  Cancer  of  the  stomach 
is  apt  to  involve  secondarily  adjacent  organs  or  structures, 
especially  the  liver.  In  many  doubtful  cases  exploratory 
incision  is  justifiable. 

Treatment. — The  vicdical  treatment  consists  in  milk-diet, 
and  the  use  of  morphin  and  of  lavage  if  the  pylorus  or 
body  of  the  stomach  is  diseased.  Perform  lavage  as  follows  : 
The  tube  for  lavage  should  be  long  enough  to  extend 
about  three  feet  out  of  the  mouth  when  the  other  end  is  in 
the  stomach,  it  should  be  flexible,  should  have  an  opening 
in  the  stomach-end  and  another  opening  on  the  side  about 
one  inch  above  the  stomach-end.  The  tube  should  be 
greased  w^ith  glycerin.  The  patient  sits  down,  throws  the 
head  back,  opens  the  mouth  widely,  and  is  directed  to  take 
deep  breaths  at  regular  intervals.  The  tube  is  carried  into 
the  pharynx,  the  patient  is  ordered  to  make  efforts  to 
swallow  it,  and  the  tube  is  thus  taken  into  the  stomach. 
About  one  quart  of  fluid  is  poured  into  the  funnel-like  end 
of  the  tube,  and  just  before  the  tube  empties  itself  of  the  last 
of  the  water  the  funnel  is  lowered  and  the  fluid  runs  out. 
This  proceeding  is  repeated  till  the  fluid  becomes  clear.  The 
best  fluid  to  use  is  a  solution  of  bicarbonate  of  sodium,  a 
teaspoonful  to  a  quart  of  warm  water.     Lavage  should  be 


PEPTIC   ULCER    OF   THE   STOMACH.  77 1 

practised  before  breakfast,  and  sometimes  also  at  bed- 
time. 

Surgical  treatment  aims  at  the  removal  of  the  growth,  or 
obviating  the  effect  of  obstruction  at  one  of  the  orifices  of 
the  stomach. 

In  cancer  of  the  body  of  the  stomach,  if  the  growth  is  not 
extensive,  excision  may  be  performed ;  if  it  is  extensive,  it  is 
useless  to  attempt  it  unless  the  growth  is  absolutely  non- 
adherent. Schlatter  of  Zurich,  Brigham  of  San  Francisco, 
Richardson  of  Boston,  and  Macdonald  of  San  Francisco  have 
successfully  removed  the  entire  stomach  and  attached  the 
esophagus  to  the  small  intestine.  In  these  cases  digestion 
was  satisfactorily  performed  after  removal  of  the  stomach. 
Very  rarely  will  cases  be  found  suitable  for  such  a  radical 
proceeding.  The  case  suitable  for  this  treatment  is  one  in 
w^hich  the  entire  stomach  is  involved  in  the  growth,  in  which 
there  is  no  obvious  glandular  involvement,  and  in  which  the 
stomach  is  not  adherent  but  is  freely  movable.  In  cancer 
of  the  cardiac  orifice  of  the  stomach  the  surgeon  usually 
keeps  the  passage  open  as  long  as  possible  by  the  frequent 
passage  of  a  tube,  and  through  this  tube  introduces  liquid 
food.  Sometimes  a  small  tube  is  introduced  and  permanently 
retained.  When  it  becomes  difficult  to  introduce  a  tube 
gastrostomy  is  performed.  A  better  rule  is  to  perform  gas- 
trostomy as  soon  as  there  is  difficulty  in  swallowing  liquids. 
In  cancer  of  the  pylorus  limited  in  extent  and  without 
lymphatic  involvement,  pylorectomy  may  be  performed  ;  but 
in  cancer  which  has  widely  infiltrated  the  coats  of  the  stom- 
ach and  has  involved  the  lymphatic  glands,  gastro-enteros- 
tomy  is  performed  as  a  palliative  measure,  the  patient  during 
the  rest  of  his  life  subsisting  upon  liquid  or  semiliquid  foods 
and  submitting  to  frequent  irrigation  of  the  stomach  to  re- 
move food-residue.  In  cases  of  irremovable  cancer  it  is 
usuall}'  best  to  create  the  opium-habit. 

Peptic  Ulcer  of  the  Stomacli. — Ulcer  of  the  stomach 
is  a  condition  due  to  digestion  of  a  portion  of  the  stomach- 
wall  by  very  acid  gastric  juice,  the  destroyed  portion  having 
been  the  seat  of  lowered  vitality. 

Ulcers  are  more  common  in  females  than  in  males,  and  are 
more  frequent  in  young  women  than  in  those  of  middle  or 
advanced  age.  Men  about  forty  and  w^omen  under  forty  are 
particularly  liable.  There  is  usually  a  single  ulcer,  but  in  some 
cases  there  are  two  or  more.  The  ulcer  may  heal  or  may 
perforate.  The  most  common  seats  of  ulcer  are  the  pos- 
terior wall    and    lesser    curvature,  especially  in  the  pyloric 


'J'J2      DISEASES  AND   INJURIES    OF   THE   ABDOMEN. 

region.  Only  2  per  cent,  of  ulcers  on  the  posterior  wall 
perforate,  as  they  tend  to  form  adhesions  to  adjacent 
structures  (Alderson).  Ulcers  on  the  anterior  wall  are  un- 
usual, do  not  tend  to  form  adhesions,  and  are  apt  to  per- 
forate. Disorder  of  menstruation  may  develop  ulcer,  so  may 
tight  lacing,  and  habitually  bending  over,  as  in  making  shoes. 
Chlorosis  is  associated  with  ulcer  in  may  cases.  Traumatism 
and  swallowing  corrosive  liquid  may  lead  to  ulceration. 
Alderson  believes  that  alcoholism,  syphilis,  and  mental 
anxiety  may  lead  to  the  condition.  Ulcers  due  to  syphilis 
and  tubercle  are  not,  be  it  remembered,  peptic  ulcers. 

Symptoms. — Acid  dyspepsia  exists,  associated  with  much 
flatulence.  In  most  cases,  though  not  in  all,  food  aggra- 
vates the  condition.  In  many  of  these  patients  vomiting 
occurs  about  two  hours  after  eating.  The  vomited  matter 
contains  much  hydrochloric  acid.  Hemorrhage  from  the 
stomach  tends  to  occur.  The  blood  may  be  brought  up 
with  food,  and  is  then  black  and  clotted,  or  may  be  vomited 
clear  and  in  large  amount.  In  some  cases  blood  from  the 
stomach  is  passed  by  the  bowels  in  part  or  wholly.  Paroxys- 
mal pain  exists,  which  is  usually,  but  not  invariably,  aggra- 
vated by  taking  food.  The  pain  is  very  violent  in  the  abdo- 
men, and  also  passes  to  the  back,  being  located  between  the 
eighth  and  ninth  lumbaf^vertebrae. 

In  gastric  ulcer  it  is  usual  to  find  tenderness  developed  by 
abdominal  pressure. 

If  the  ulcer  does  not  cicatrize,  but  progresses,  causing 
pain  and  hemorrhage,  the  patient  becomes  thin,  anemic, 
weak,  and  even  exhausted. 

It  is  highly  probable  that  many  cases  of  gastric  ulcer  are 
unrecognized ;  in  fact,  as  Habershon  says,  diagnosis  is  rarely 
made  unless  hemorrhage  exists,  and  in  certain  latent  cases 
both  vomiting  and  bleeding  are  absent. 

A  gastric  ulcer  may  cicatrize  and  thus  become  cured ;  but 
the  cure  of  the  ulcer  may  prove  the  ruin  of  the  stomach  by 
producing  stenosis  of  one  of  the  stomach-orifices  or  hour- 
glass contraction  of  the  body  of  the  stomach.  An  ulcer 
may  perforate,  causing  sudden  violent  pain,  greatly  increased 
by  swallowing  fluids,  acute  abdominal  tenderness,  muscular 
rigidity,  and  rapidly  increasing  collapse.  In  some  cases 
death  quickly  happens  in  collapse;  in  other  cases  there  are 
temporary  reaction  and  the  onset  of  acute  peritonitis.  Vom- 
iting is  unusual  after  rupture.  The  area  of  liver-dulness  is 
diminished  or  abolished.  Perforation  occurs  after  a  meal  or 
after    drinking   liquid,  and  is    brought  about    by  muscular 


CICATRICIAL    STENOSIS   OF  ORIFICES   OF  STOMACH.    773 

effort.  Alderson  calls  attention  to  the  fact  that  the  sudden 
perforation  of  an  ulcer  may  be  mistaken  for  poisoning,  and 
he  cites  the  death  of  the  Duchess  of  Orleans  in  1670.' 

Treatment. — Medical. — Rest  in  bed.  Rectal  feeding  for 
a  time,  followed  by  the  use  of  a  bland  diet.  Lav^age  twice 
a  day.  To  some  cases  Carlsbad  salts  are  given  (Ziemssen), 
to  others  silver  nitrate,  bismuth  subnitrate,  or  oxalate  of 
cerium.     If  pain  is  severe,  opium  is  required. 

Surgical. — If  the  patient  grows  worse  in  spite  of  medical 
treatment,  if  the  hemorrhage  has  been  profuse,  if  the  pain 
is  violent,  or  if  tenderness  is  marked,  open  the  abdomen  and 
inspect  the  stomach.  An  ulcer  ma}'  be  removed  by  an 
elliptical  incision  in  the  long  axis  of  the  stomach,  the  coats 
being  sutured  by  the  usual  method.  If  the  patient  is  bleed- 
ing to  death  because  of  an  ulcer,  open  the  abdomen  while 
an  assistant  is  giving  an  intravenous  injection  of  salt  solu- 
tion, open  the  stomach,  turn  out  clot,  find  the  source  of 
bleeding,  and  excise  the  ulcer.  In  perforation  bring  about 
reaction  from  shock  and  open  the  abdomen.  When  the 
abdomen  is  opened  there  is  an  escape  of  odorless  gas 
(Aufray),  and  food  or  fluid  may  be  discovered  in  the  perito- 
neal cavit}\  There  may  be  adhesions.  The  perforation  is 
found  and  excised,  the  stomach  is  washed  out,  the  perfora- 
tion is  sutured,  the  abdominal  cavity  is  cleansed,  drainage  is 
inserted,  and  the  wound  is  sutured.  Of  late  a  number  of 
cases  have  been  successfully  operated  upon  (see  Barling, 
etc.). 

Cicatricial  stenosis  of  the  orifices  of  the  stomach 
results  from  the  healing  of  an  ulcer,  the  swallowing  of  a 
corrosive  substance,  or  traumatism  from  a  foreign  body. 
Constriction  of  the  cardiac  orifice  is  indicated  by  gradually 
increasing  difficulty  in  swallowing.  After  a  time  the  esopha- 
gus above  the  stricture  dilates  or  pouches  ;  the  fluid  food 
passes  into  the  stomach,  but  the  solid  food  lodges  in  the 
esophageal  pouch  and  is  soon  regurgitated.  The  site  of  the 
stiicture  is  located  by  a  bougie,  and  by  having  the  patient 
swallow  while  auscultating  over  the  esophagus  and  cardiac 
end  of  the  stomach.  If  the  constriction  be  malignant,  the 
patient  will  be  found  to  be  beyond  middle  life,  the  vomit  is 
occasionally  bloody,  emaciation  is  rapid  and  decided,  and 
occasionally  the  supraclavicular  glands  are  enlarged.  A 
tumor  of  the  cardiac  end  of  the  stomach  can  rarely  be  felt. 
If  the  constriction  be  cicatricial,  the  histor}^  will  indicate  the 
cause.     Constriction   of  the  pyloric  orifice  causes   retention 

^  Provincial  Medical  Journal,  Dec.  2,  1S95. 


774      DISEASES  AND   INJURIES   OF   THE  ABDOMEN. 

of  food  and  dilatation  of  the  stomach.  Dyspeptic  symp- 
toms will  be  found  to  have  been  long  present.  A  tube 
passed  into  the  stomach  permits  of  the  injection  of  fluid  so 
as  to  fill  the  stomach.  When  the  fluid  runs  out  it  contains 
portions  of  undigested  food  eaten  days  before,  and  measure- 
ment of  the  liquid  shows  that  the  capacity  of  the  stomach 
is  enormously  increased.  If  hydrogen  be  forced  through 
the  tube,  the  outline  of  the  distended  stomach  is  at  once 
made  clear.  The  usual  method  of  distending  the  stomach 
is  by  Seidlitz  powder:  two  solutions  are  made;  the  bicar- 
bonate solution  is  swallowed  at  once,  and  the  tartaric  solu- 
tion is  taken  afterward  in  small  amounts  at  a  time.  Percus- 
sion over  the  distended  stomach  indicates  the  size  of  the 
viscus. 

In  malignant  disease  of  the  pylorus  a  tumor  may  often 
be  made  out;  there  are  tenderness  and  considerable  persist- 
ent pain,  great  cachexia  and  emaciation,  absence  of  free 
hydrochloric  acid  from  the  gastric  juice,  diminution  of  red 
corpuscles  and  hemoglobin,  and  no  increase  of  white  cor- 
puscles after  a  full  meal.  There  is  sometimes  enlargement 
of  the  supraclavicular  glands.  Vomiting  of  bloody  fluid 
occurs  in  40  per  cent,  of  cases.  Illumination  of  the  stomach 
by  the  gastrodiaphanoscope  may  aid  the  diagnosis,  the  area 
of  malignant  growth  interfering  with  the  transmission  of 
light.  In  cicatricial  stenosis  of  the  pylorus  there  may  be 
paroxysms  of  pain,  there  is  no  tenderness,  emaciation  is 
not  so  rapid  in  onset,  and  the  supraclavicular  glands  are 
never  enlarged.  Vomiting  occurs,  but  the  ejected  matter  is 
not  bloody. 

Treatment. — Cicatricial  cardiac  stenosis  requires  dilatation 
with  bougies  and  the  maintenance  of  the  restored  caliber.  If 
dilatation  from  above  is  unsatisfactory,  perform  a  gastrotomy, 
push  a  small  bougie  from  the  mouth  into  the  stomach,  tie  a 
string  to  the  bougie,  draw  the  string  through  the  stricture,  use 
the  string  as  a  saw  to  cut  the  fibrous  bands,  pass  a  full- 
sized  bougie,  close  the  wound  in  the  stomach,  and  maintain 
the  caliber  of  the  cardiac  orifice  by  the  repeated  passage 
of  dilating  instruments.  If  no  instrument  can  be  passed 
through  the  stricture  from  above,  perform  a  gastrotomy, 
introduce  an  instrument  from  below  and  pass  it  into  the 
mouth,  tie  a  string  to  it,  draw  the  string  into  the  stomach, 
and  use  Abbe's  string-saw.  If  no  instrument  can  be  passed 
from  below,  convert  the  gastrotomy  into  a  gastrostomy. 
In  malignant  stenosis  of  the  cardia  gastrostomy  should  be 
performed  early.     Cicatricial  pyloric  stenosis  is  treated  by  a 


INTESTINAL    OBSTRUCTION.  7/5 

gastrotomy  and  digital  divulsion  of  the  stricture  (Loreta's 
operation),  by  pyloroplasty  (Heineke-Mikulicz  operation),  or 
by  gastro-enterostomy.  Malignant  stenosis  is  treated  by 
pylorectomy  or  gastro-enterostomy.  (See  under  these  heads 
respectively). 

Intestinal  Obstruction  (Ileus  or  Enterostenosis). — 
Intestinal  obstruction  is  a  condition  in  which  fecal  movement 
is  mechanically  impeded  or  prevented.  It  may  be  either 
partial  or  complete.  Acute  obstruction  is  due  to  a  sudden 
narrowing  or  occlusion  of  the  lumen  of  a  portion  of  the 
intestine.  Chronic  obstruction  is  due  to  a  gradual  narrowing 
of  the  lumen  of  a  portion  of  the  intestine,  and  it  may  at  any 
time  become  acute.  If  obstruction  to  circulation  in  the  wall 
of  the  bowel  occurs,  the  condition  becomes  one  of  strangula- 
tion.    Intestinal  obstructions  are  classified^  as  follows: 

1.  Strangulation  by  bands  or  in  apertures,  the  commonest 
form,  is  due  to  peritoneal  adhesions,  but  the  band  may  come 
from  the  omentum.  Strangulation  may  take  place  by 
Meckel's  diverticulum,  a  structure  due  to  persistence  of  the 
vitelline  duct,  and  coming  off  from  the  ileum  from  twelve  to 
thirty-six  inches  above  the  ileocecal  valve.  Strangulation 
may  take  place  beneath  an  adherent  appendix,  a  Fallopian 
tube,  a  portion  of  mesentery,  or  the  pedicle  of  an  ovarian 
tumor,  or  it  may  take  place  in  an  omental  or  a  mesenteric 
aperture.  Strangulation  by  bands  or  in  apertures  usually 
involves  the  ileum,  and  sometimes  the  colon.  This  form  of 
obstruction  is  identical  with  hernia,  excepting  in  the  absence 
of  an  external  protrusion. 

2.  Volvulus,  or  twisting  of  the  bowel.  The  twist  may  be 
about  the  mesenteric  axis  or  on  the  axis  of  the  bowel  itself, 
or  two  intestinal  coils  may  be  twisted  together.  Volvulus  is 
commonest  in  the  sigmoid  flexure.  It  may  occur  in  a  her- 
nial sac. 

3.  Intussusception  is  the  invagination  of  a  portion  of  bowel- 
wall  into  the  lumen  of  an  adjacent  part.  One-third  of  all 
cases  of  obstruction  are  due  to  this  cause  (Treves).  Most 
cases  of  obstruction  in  children  are  due  to  intussusception. 
There  are  four  varieties  :  the  ileocecal,  in  which  the  ileum 
and  the  ileocecal  valve  pass  into  the  cecum  and  colon  ;  the 
colic,  in  which  the  large  intestine  is  prolapsed  into  itself;  the 
ileal,  in  which  the  small  intestine  alone  is  involved ;  and  the 
ileocolic,  in  which  the  ileum  prolapses  through  the  ileocecal 
valve.  The  first  variety  is  the  commonest.  Intussusception 
is  due  to  active  peristalsis. 

1  After  Treves,  in  Heath's  Dictionary. 


']']6      DISEASES  AND   INJURIES   OF   THE  ABDOMEN. 

4.  Stricture  of  the  intestine,  which  may  be  either  cicatricial 
or  cancerous. 

5.  Obstmction  by  Tumors  of  the  Bowel  and  by  Foreign 
Bodies. — Tumors  may  be  innocent  or  mahgnant.  Foreign 
bodies  include,  besides  certain  substances  that  have  been 
swallowed,  gall-stones,  and  enteroliths  or  intestinal  calculi. 
Foreign  bodies  are  apt  to  lodge  in  the  lower  portion  of  the 
ileum  or  in  the  cecum,  and  they  may  cause  ulceration  at 
the  seat  of  lodgement.  If  a  gall-stone  is  sufficiently  large 
to  cause  obstruction,  it  cannot  have  passed  the  duct,  but 
must  have  ulcerated  into  the  bowel  from  the  gall-bladder 
(Treves). 

6.  Obstruction  by  tumors,  etc.,  outside  the  bowel,  among  the 
causes  of  which  are  retroflexion  or  retroversion  of  the  womb, 
especially  in  pregnancy,  cysts  or  tumors  of  the  kidneys, 
ovaries,  uterus,  etc.,  floating  kidney,  and  enlarged  spleen. 
Obstruction  from  any  of  the  above  causes  takes  place  in  the 
rectum  or  the  sigmoid  flexure. 

7.  Obstructioji  from  fecal  accicmidation  is  due  to  paresis 
or  paralysis  of  the  bowel  and  the  diminution  or  abolition  of 
peristalsis.  Obstruction  may  follow  an  abdominal  oper- 
ation. Paresis  or  paralysis  arises  in  the  colon.  Treves 
mentions  among  the  rare  forms  of  obstruction  kinking  of 
the  bowel,  adhesions  matting  the  bowels  together  or  com- 
pressing the  gut,  and  shrinking  of  the  mesentery. 

Symptoms  of  Acute  Obstruction. — Severe  colic  comes 
on  suddenly,  the  pain  varying  in  intensity,  but  at  no  time 
entirely  ceasing.  In  a  suddenly  arising  intraperitoneal  acci- 
dent, whether  it  be  perforation,  acute  obstruction,  or  acute 
strangulation,  there  is  at  first  shock,  from  which  the  patient 
usually  reacts  for  a  time.  There  is  constipation,  which  soon 
becomes  absolute,  not  even  wind  being  passed ;  vomiting  is, 
early — first  of  the  contents  of  the  stomach,  next  of  bilious 
matter,  and  finally  of  feces  (stercoraceous) ;  the  abdomen 
becomes  distended  and  tender.  After  reaction  from  shock 
some  fever  may  be  noted,  but  in  any  unrelieved  case  collapse 
soon  arises  ;  the  temperature  becomes  subnormal ;  the  face 
Hippocratic ;  the  pulse  rapid  and  feeble.  The  amount  of 
urine  passed  is  very  small.  In  obstruction  of  the  upper  third 
of  the  ileum  true  fecal  vomiting  cannot  occur.  The  tongue 
is  dry,  the  mind  is  clear,  and  muscular  cramp  may  occur. 
Intestinal  peristalsis  above  the  obstruction  may  be  detected 
through  the  abdominal  wall.  If  obstruction  is  high  up  in 
the  small  intestine,  tympanites  does  not  occur. 

Syraptoms  of  Chronic  Obstruction. — At  intervals  there 


IaYTESTinal  obstruction.  yyj 

arise  attacks  of  pain  which  become  gradually  more  frequent 
and  severe,  and  are  Hnked  with  vomiting  and  constipation, 
the  vomiting  not  being  stercoraceous  and  the  constipation 
not  being  absokite.  Between  the  painful  seizures  the  patient 
complains  of  constipation  alternating  with  fluid  diarrhea,  dis- 
tention of  the  belly,  some  abdominal  uneasiness,  anorexia, 
and  dyspepsia.  The  attacks  recur  with  increasing"  frequency 
and  severity,  and  acute  obstruction  may  arise  or  the  patient 
may  be  worn  out  b}-  pain,  vomiting,  and  want  of  food. 

Diagnosis. — The  detcrniination  of  the  seat  of  lesion  requires 
abdominal  and  rectal  examination.  An  intussusception  may 
sometimes  be  felt.  Vaginal  examination  may  be  demanded. 
Pain  is  apt  to  arise  at  the  seat  of  obstruction  or  to  radiate 
from  there.  Palpation  ma}'  detect  a  tumor.  Rectal  insufflation 
of  hydrogen  may  locate  the  obstruction  by  causing  great  dis- 
tention below  it.  Entire  suppression  of  urine,  early  vomiting 
which  is  not  truly  stercoraceous,  absence  of  abdominal  disten- 
tion, and  rapid  collapse  mean  obstruction  in  the  duodenum  or 
in  the  jejunum.  Early  vomiting,  which  is  often  stercoraceous 
in  a  rapid!}'  progressive  case  wdth  great  distention  of  the 
umbilical  region,  means  obstruction  of  the  ileum  or  the 
cecum.  Distention  of  the  entire  abdomen  and  of  the  flanks, 
linked  with  tenesmus,  with  less  intensity  of  symptoms,  less 
rapidity  of  progress,  and  less  diminution  of  urine  than  in 
the  above-cited  forms,  means  obstruction  low  down  in  the 
colon  or  in  the  rectum.  A  test  for  obstruction  in  the 
adult  large  intestine  is  an  injection  by  a  fountain-syringe ; 
if  six  quarts  can  be  introduced,  there  is  no  obstruction  in 
the  large  intestine;  if  less  than  four  quarts  can  be  intro- 
duced, there  is  probabh'  obstruction  in  the  large  intestine. 
The  passage  of  a  sound  in  the  rectum  is  generally  useless 
and  is  often  unsafe. 

The  determination  of  the  causative  condition  is  always  diffi- 
cult and  is  often  impossible.  Intussusception  is  the  common 
cause  in  children.  A  sausage-shaped  tumor  can  usually  be 
felt  in  the  right  iliac  fossa,  tenesmus  exists,  and  bloody 
mucus  is  passed.  The  abdomen  is  rarely  distended  or  tender. 
Vomiting  occurs,  but  it  is  seldom  stercoraceous.  The  pro- 
lapse ma}'  sometimes  be  detected  b}-  digital  exploration  of 
the  rectum.  In  obstruction  from  bands,  internal  hernia,  etc., 
there  is  a  record  of  antecedent  peritonitis,  of  a  traumatism, 
of  a  violent  effort,  or  of  pelvic  pain.  The  attack  is  sudden 
in  onset,  is  fierce  in  character,  and  is  usually  excited  by  vio- 
lent exercise  or  the  taking  of  food.  Vomiting  is  earh'  and 
intractable,  and  it  soon  becomes  stercoraceous;  pain  is  vio- 


J-jZ      DISEASES  AND   IXJURIES   OF   THE  ABDOMEN. 

lent;  peristalsis  above  the  obstruction  is  forcible;  tympan- 
ites and  abdominal  tenderness  appear  after  the  attack  has 
lasted  for  some  little  time ;  obstruction  is  complete,  no  wind 
even  being  passed;  collapse  soon  arises;  no  tumor  can 
be  detected,  and  rectal  examination  is  negative.  Volvulus, 
which- is  usually  located  in  the  sigmoid  flexure,  is  preceded 
by  constipation.  The  symptoms  come  on  with  explosive 
suddenness,  and  rapidly  attain  great  severity.  Constipation 
is  absolute;  vomiting  is  late  and  is  rarely  stercoraceous ;  no 
tumor  can  be  detected;  rectal  examination  is  negative;  ab- 
dominal distention  and  tenderness  are  early  and  pronounced; 
peristalsis  above  the  volvulus  is  vigorous ;  collapse  is  not  so 
rapid  nor  so  grave  as  in  the  previously-considered  forms. 
Obstruction  by  a  foreign  body  may  sometimes  be  inferred 
from  the  history  of  some  such  body  having  been  swallowed. 
The  obstructing  body  may  occasionally  be  felt  during  pal- 
pation, or  may  be  discovered  with  the  ;i'-rays.  Abdominal 
distress  may  exist  for  days  or  weeks  before  obstruction 
occurs.  Vomiting  is  late  and  is  rarely  severe,  but  pain,  ten- 
derness, and  distention  are  marked.  In  obstruction  from 
gall-stones  there  will  be  a  record  of  one  or  more  attacks  of 
hepatic  colic.  Pain  is  early  and  acute,  and  vomiting  is 
invariable  and  usually  becomes  stercoraceous.  In  obstruc- 
tion from  fecal  accumulation  chronic  obstruction  evolves  into 
acute  obstruction,  pain  and  vomiting  are  late  or  even  absent, 
and  the  dough-like  mass  of  feces  may  often  be  felt  by  rectal 
examination  or  by  abdominal  palpation.  In  some  cases  the 
fluid  elements  of  the  feces  pass,  but  the  solid  elements 
agglutinate  to  the  walls  of  the  bowel  (the  diarrhea  of  consti- 
pation). Obstruction  from  stricture  or  from  pressure  comes 
on  acutely  after  a  prolonged  period  of  disturbance,  during 
which  period  attack  after  attack  of  temporary  obstruction, 
complete  or  partial,  takes  place.  A  history  of  blood  or  pus 
in  the  stools  would  indicate  tumor  of  the  bowel ;  a  history 
of  blood  or  pus  having  been  absent  would  indicate  pressure 
from  without  (Pepper).  In  functional  obstruction  there  is  no 
local  pain,  no  tenderness,  no  tumor,  no  tendency  to  collapse, 
but  simply  distention  and  absolute  constipation,  and  possibly 
nqn-fecal  vomiting  occurring  in  a  neurotic  or  hysterical  sub- 
ject. A  phantom  tumor  due  to  a  local  distention  of  the 
intestine  from  limited  muscular  spasm  disappears  under 
ether.  Obstruction  may  follow  an  abdominal  operation  (post- 
operative obstruction);  it  may  arise  a  day  or  so  after  oper- 
ation ;  it  may  arise  in  ten  or  twelve  days  after  operation  ;  it 
may  not  arise  for  weeks  or  months  (Legeve).     It  may  be  due 


IXTESTIXAL    OBSTRUCTIOX.  779 

to  some  cause  at  the  seat  of  operation  (adhesion  of  the  bowel 
to  a  raw  surface,  volvulus,  catching  of  the  intestine  under 
adhesions,  etc.).  It  may  be  due  to  some  cause  distant  from 
the  seat  of  operation  (^displacement  of  intestine,  bands,  etc.  i. 
It  may  arise  from  paralysis  of  a  portion  of  the  bowel,  which 
may  or  may  not  be  due  to  sepsis.^ 

Recognition  of  Intestinal  Obstruction  from  Other  Diseases.— 
Always  examine  for  a  strangulated  hernia  at  every  hernial 
outlet.  If  obstruction  is  complicated  with  an  irreducible 
hernia  above  the  seat  of  lesion,  the  hernia  will  always  en- 
large and  become  tender  because  of  accumulation  of  feces. 
Functional  obstruction  may  attend  peritonitis  or  may  fol- 
low the  reduction  of  a  hernia.  Appendicitis  with  peri- 
tonitis may  cause  symptoms  similar  to  those  of  obstruc- 
tion ;  but  there  are  fever,  a  histor}^  of  pain  in  the  right  iliac 
fossa,  and  the  vomiting  is  not  stercoraceous.  Acute  hemor- 
rhagic pancreatitis  produces  symptoms  so  nearly  identical  with 
those  of  intestinal  obstruction  that  a  diagnosis  cannot  always 
be  made.  Poisoning  by  arsenic  or  by  corrosive  subhmate 
should  not  be  confounded  with  intestinal  obstruction. 

Prognosis.— Without  surgical  interference  most  cases  of 
acute  intestinal  obstruction  die  within  ten  days,  usually  within 
seven  davs.  Death  may  be  due  to  shock,  to  exhaustion,  to 
perforation,  to  peritonitis,  or  to  obstruction  of  respiration  and 
circulation  bv  t\-mpanites.  Recover}-  occasionally  happens 
by  the  formation  of  a  fistula  externally  or  into  another  por- 
tion of  the  bowel.  In  acute  obstruction  from  foreign  bodies 
the  obstructing  body  occasionally  passes.  Volvulus  and 
strangulation  by  bands  are  almost  invariably  fatal  unless  an 
operation  is  performed.  In  intussusception  recover}-  occa- 
sionally follows  the  sloughing  away  of  the  prolapsed  gut,  but 
stricture  almost  inevitably  results  from  this  rare  event.  Func- 
tional obstruction  gives  a  good  prognosis.  The  prognosis 
of  chronic  obstruction  depends  upon  the  causative  lesion, 
and  is  not  nearly  so  grave  as  is  that  of  acute  obstruction. 

Treatment. — In  any  abdominal  case,  where  the  diagnosis  is 
uncertain  and  the  patient  is  shocked,  give  an  enema  of  brandy 
and  hot  water,  wrap  the  patient  in  blankets,  surround  him 
with  hot-water  bottles,  and  study  the  development  of  symp- 
toms and  signs.  In  half  an  hour,  as  a  rule,  reaction  will  be 
brought  about,  and  a  probable  diagnosis  may  be  made  (Greig 
Smith).  In  acute  obstruction  it  is  usually  customar}-  to 
empty  the  stomach  by  lavage  and  to  evacuate  the  rectum 
by  means  of  copious  injections  given  while  the  patient  is  in 

1  Legeve,  Gaz.  des  Hop.,  November  23,  1S95. 


780      DISEASES  AND   INJURIES   OF  THE  ABDOMEN. 

the  knee-chest  position.  Hutchinson's  method  of  taxis  and 
massage  is  uncertain,  and  is  as  hable  to  inflict  harm  as 
to  confer  benefit.  Some  surgeons  apply  constant  compres- 
sion to  the  abdomen  by  means  of  straps  of  adhesive  plaster. 
Puncture  of  the  intestine  with  an  aseptic  hypodermatic  needle 
introduced  obliquely  to  relieve  gaseous  distention  is  a  de- 
cidedly dangerous  proceeding.  The  passage  of  a  small  tube 
from  the  anus  to  the  sigmoid  flexure  will  empty  the  colon  of 
gas  if  no  obstruction  intervenes.  In  intussusception  give 
no  food  by  the  stomach;  give  opium  and  belladonna  to  stop 
peristalsis,  wash  out  the  rectum  with  copious  injections,  give 
an  anesthetic,  and  insufflate  hydrogen  gas  or  carbonic  acid  gas 
in  order  to  distend  the  bowel.  Some  surgeons  treat  intussus- 
ception by  forcing  air  into  the  rectum  by  means  of  an  ordinary 
bellows,  and  others  inject  water  by  a  fountain-syringe,  the 
reservoir  standing  at  a  height  of  three  feet.  D'Arcy  Power 
believes  in  the  value  of  hydrostatic  pressure  in  intussuscep- 
tion in  children.  He  states  that  the  child  should  be  anesthet- 
ized and  the  large  intestine  filled  gradiially  with  hot  saline 
fluid,  the  reservoir  not  being  raised  more  than  three  feet 
above  the  patient.  The  fluid  should  be  retained  for  ten 
minutes.  The  author  is  of  the  opinion  that  injections  of  gas 
or  liquid  should  be  tried  during  the  first  twenty-four  hours 
of  the  attack,  but  not  later,  because  later  ulcer  or  gangrene 
may  exist.  Pressure  cannot  be  accurately  regulated,  and  if 
the  bowel  is  much  damaged  may  lead  to  rupture.  If  the 
case  is  not  seen  until  after  the  first  day,  or  if  injections  have 
been  used  and  have  failed,  laparotomy  should  be  performed. 

Frederick  Holme  Wiggin  has  made  a  study  of  the  reported 
cases  of  laparotomy  for  infantile  intussusception,  and  con- 
siders that  operation  done  within  the  first  forty-eight  hours 
will  give  a  mortality  of  22.2  per  cent.^  (see  Operation  for  In- 
tussusception). 

In  obstruction  from  fecal  impaction  use  large  rectal  injec- 
tions and  give  small  repeated  doses  of  salines  or  of  a  mixture 
of  castor  oil  and  oil  of  turpentine.  If  there  are  signs  of  in- 
flammation, do  not  give  cathartics,  even  in  small  doses,  but 
give  opium  and  belladonna  to  arrest  vomiting  and  to  relax 
spasm.  Impactions  in  the  rectum^  can  be  removed  by  the 
use  of  a  spoon.  In  acute"  intestinal  obstruction,  if  the 
symptoms  grow  worse,  do  not  wait,  but  open  the  abdo- 
men before  collapse  comes  on  and  find  the  cause  of 
the  obstruction.  If  it  is  a  gall-stone  or  enterolith,  try 
to  crush  it  without  opening  the  intestine ;  if  this  fails,  push 

1  Medical  I\ecerd,  January  i8,  1896. 


FECAL    FISTULA.  78  I 

it  up  a  little  distance,  incise  the  bowel,  remove  the  stone, 
and  close  the  incision  with  Halsted  sutures.  If  there  is  .fecgj, 
ohstruGtioft,  break  up  the  masses  by  pressure  and  push  the 
fecal  plug  down  without  opening  the  bowel.  If  there  is 
intussusception,  reduce  the  prolapse  and  shorten  the  mesen- 
teiyj  T5ut  if~f5duction  is  impossible,  perform  an  anastomosis 
or  a  resection  and  enterorrhaphy,  or  make  an  artificial  anus. 
In  volvulus  untwist  and  shorten  the  mesentery ;  but  if  this  is 
impoSSt^e,  treat  as  an  irreducible  invagination.  In  obstruc- 
tion from  adhesions  try  to  separate  them  and  straighten  out 
the  bowelT'sfTfching  healthy  peritoneum  over  each  raw  spot 
to  prevent  recurrence.  Anastomosis  may  be  necessary.  In 
flexion_  separate  the  intestines,  remove  the  flexion  by  a 
V-shaped  incision,  and  suture  the  wound  in  the  bowel  (Senn). 
In  chronic  obstruction  it  is  often  advisable  to  perform  an  ex- 
ploratory laparotomy,  discover  the  condition,  and  determine 
what  is  to  be  done  to  correct  it.  Some  tumors  external  to 
the  bowel  may  be  removed.  Grov/ths  in  the  bowel-wall  may 
be  removed  by  resection  of  the  involved  portion  of  intestine, 
or  an  anastomosis  may  be  performed,  or  it  may  be  necessary 
to  make  an  artificial  anus.  Post-operative  obstruction 
coming  on  soon  after  a  surgical  operation  is  often  not 
recognized  for  a  time,  and  the  surgeon  will  be  in  doubt 
as  to  whether  he  is  dealing  with  peritonitis  or  intesti- 
nal paresis.  When  in  doubt  wash  out  the  stomach  with 
warm  salt  solution,  administer  salines  in  small  doses  fre- 
quently repeated,  and  employ  enemata.  If  these  measures 
are  not  soon  successful,  open  the  abdomen  ;  never  wait  for 
the  advent  of  stercoraceous  vomiting  (see  Legeve). 

Fecal  Fistula. — A  fistula  is  an  abnormal  opening  in  the 
intestine  through  which  gas  or  a  portion  of  the  feces  escapes 
(Fig.  268).     If  all  the  intestinal  contents  escape  through  the 


Fig.  268. — Fecal    fistula  :   a,  direction  Fig.  269. — Artificial  anus,  showing  spur  : 

of  fecal  flow  ;    b,  b,  belly-wall.  a,  spur;  b,  b,  belly -wall ;   c,  direction  of  fecal 

flow. 

opening,  it  is  called  an  artificial  anus  (Fig.  269,  Senn).  A 
surgeon  may  make  a  fistula  deliberately  (intentional  fistula). 
A  fistula  may  be  the  product  of  disease  or  injury  (accidental 
fistula).     Senn  enumerates  the  following  causes  of  accidental 


782      DISEASES  AND   INJURIES   OF   THE   ABDOMEN. 

fistula:  wounds,  injury  of  the  intestine,  intestinal  ulceration, 
intestinal  strangulation,  foreign  bodies  in  the  intestinal  canal, 
malignant  tumors,  actinomycosis,  pelvic  and  abdominal  ab- 
scess, appendicitis,  injury  of  the  bowel  during  an  abdominal 
operation,  the  application  of  ligatures,  catching  by  sutures, 
and  the  employment  of  drainage-tubes. 

Treatment. — Many  fistulae  close  spontaneously.  This  can 
only  be  hoped  for  if  the  opening  is  quite  small,  if  the  gen- 
eral health  of  the  patient  is  good,  if  the  cause  has  passed 
away,  if  the  fistula  is  not  lined  with  mucous  membrane, 
and  if  there  is  no  spur  (spur  is  shown  at  a,  Fig.  269).  In 
most  cases  of  fistula  not  high  up  it  is  well  to  give  Nature 
a  chance  to  effect  a  cure,  and  not  to  be  in  a  hurry  to  oper- 
ate. The  part  is  cleansed  frequently  with  peroxid  of  hydro- 
gen, the  patient  is  kept  recumbent,  food  is  given  which  does 
not  leave  much  residue,  pads  of  gauze  with  pressure  are 
applied,  and  the  bowels  are  kept  regular. 

If  the  track  is  lined  with  granulations,  it  may  be  touched 
with  lunar  caustic  ;  if  it  is  lined  with  mucous  membrane,  the 
actual  cautery  should  be  applied;  any  collection  of  pus 
which  exists  should  be  drained.  If  these  methods  fail,  an 
operation  must  be  performed.  The  fistula  may  be  sutured 
by  extraperitoneal  manipulation  (Greig  Smithj ;  it  may  be 
covered  with  skin  (Dieffenbach) ;  the  spur  may  be  removed 
by  means  of  a  clamp ;  or  resection  may  be  performed.  In 
most  cases  it  is  best  to  incise  a  button  of  skin  around  the 
opening,  temporarily  suture  the  fistula,  open  the  peritoneal 
cavity,  deliver  the  bowel,  and  suture  carefully  (Senn's 
method).  In  some  cases  exclusion  of  the  fistulous  part  is 
necessary,  the  bowel  being  divided  above  the  fistula,  the 
end  near  the  fistula  sutured,  and  the  other  end  anastomosed 
to  the  bow^el  below  the  fistula. 

Ulcer  of  the  Bowel. — In  typhoid  fever  and  in  dysentery 
ulceration  occurs.  An  ulcer  may  be  due  to  tuberculosis  or 
cancer.  Ulcer  in  the  duodenum  sometimes  follows  a  severe 
burn  of  the  cutaneous  surface  of  the  body  (Curling's  ulcer). 
An  ulcer  may  heal,  and  by  causing  thickening  and  constric- 
tion produce  intestinal  obstruction.  It  may  perforate,  caus- 
ing collapse  and  subsequent  peritonitis.  In  perforation  the 
liver-dulness  is  greatly  diminished  or  disappears  because 
of  free  gas  in  the  peritoneal  cavity.  Perforation  of  a 
typhoid  ulcer  is  preceded  and  accompanied  by  marked 
leukocytosis ;  there  is  great  shock,  which  is  usuall)-^  fol- 
lowed by  a  temporary  reaction,  severe  pain,  as  a  rule,  ten- 
derness, costal    respiration,  abdominal    distention,  vomiting 


APPENDICITIS.  783 

which   may  become  eventually  stercoraceous,  constipation, 
pcrcussion-dulness  in  the  flanks,  and  Hippocratic  face. 

Treatment, — The  intestinal  obstruction  due  to  the  healing 
of  an  ulcer  is  treated  by  intestinal  anastomosis  or  resection. 
If  an  ulcer  perforates,  the  surgeon  aims  to  bring  about  re- 
action. If  this  attempt  succeeds,  the  abdomen  is  opened  and 
is  flushed  with  hot  saline  fluid,  special  care  being  taken  to 
cleanse  the  pelvis,  the  peritoneal  fossae,  and  the  space 
between  the  liver  and  diaphragm.  In  perforation  Finney 
always  eviscerates,  closes  the  perforation,  wipes  out  the 
peritoneal  cavity  with  gauze  pads,  and  returns  the  bowels 
slowly  into  the  abdomen,  wiping  them  carefully.  The  per- 
foration is  to  be  sought  for,  and  when  found  is  to  be  sutured. 
It  is  not  necessary  to  excise  it.  A  suprapubic  incision,  in 
addition  to  the  first  incision,  affords  better  drainage,  and  in 
some  cases  posterior  drainage  is  obtained  by  an  incision 
through  the  right  kidney  pouch.  A  drainage-tube  is  placed 
in  each  incision,  and  a  tube  is  inserted  in  the  suprapubic 
incision  and  is  carried  into  Douglas's  pouch,  and  the  upper 
incision  is  left  open,  strands  of  iodoform  gauze  being  placed 
over  the  area  of  rupture  and  in  several  places  among  the 
intestines. 

Malignant  Tumor  of  the  Intestine. — Sarcoma  is  very 
rare,  but  does  sometimes  arise,  particularly  in  young  persons, 
and  it  enlarges  ver>^  rapidly.  Cancer  is  not  uncommon,  attack- 
ing especially  the  middle  aged.  It  is  most  common  in  the 
neighborhood  of  the  ileocecal  valve  and  in  the  sigmoid  flex- 
ure. It  produces  pain  at  the  seat  of  growth,  and  after  a  time 
intestinal  obstruction.  It  is  usually  possible  to  feel  the  tunior, 
which  is  hard  and  immovable.  The  patient  wastes  rapidly 
and  is  apt  to  occasionally  pass  blood  at  stool.  The  growth 
is  not  very  rapid  and  glands  are  not  involved  early.  In 
some  cases  the  supraclavicular  glands  enlarge. 

Treatment. — Early  in  the  case  exploratory  laparotomy 
should  be  performed,  followed  if  possible  by  excision  with 
end-to-end  approximation.  If  excision  is  impossible,  the 
growth  should  be  sidetracked  by  performing  lateral  anasto- 
mosis. In  advanced  cancer  of  the  large  bowel,  if  resection 
is  impossible,  make  an  artificial  anus  above  the  tumor. 

Appendicitis. — Appendicitis,  which  is  an  inflammation 
of  the  vermiform  appendix  of  the  cecum,  is  almost  invariably 
the  primary  lesion  of  all  of  those  various  conditions  known 
as  typhlitis,  perityphlitis,  paratyphlitis,  etc. — terms  which  no 
longer  imply  pathological  entities,  and  are  in  most  instances 
well  relegated  to  obscurity.     It  was  recognized  by  some  ob- 


784      DISEASES  AND   INJURIES   OF   THE   ABDOMEN 

servers  many  years  ago  that  such  a  disease  existed,  but  the 
majority  of  the  profession  did  not  grasp  the  fact.  In  1750 
Mestevier  of  France  reported  a  case  of  perforative  appendi- 
citis. In  1827  MelUer  described  appendicitis,  and  named 
among  its  symptoms  fixed  pain  in  the  right  iliac  fossa  and 
coHc.  He  said :  "  If  it  were  possible  to  estabhsh  with  cer- 
tainty the  diagnosis  of  this  affection,  we  could  see  the  possi- 
bility of  curing  the  patient  by  operation.  We  shall  perhaps 
some  day  arrive  at  this  result."  ^  The  appendix  is  a  diver- 
ticulum (musculomembranous  in  structure)  which  comes  from 
the  posterior  and  internal  part  of  the  head  of  the  colon,  and 
which  has  no  physiological  function  (in  herbivora  and  rodents 
it  is  a  functionally  active  organ).  The  structure  of  the  appen- 
dix is  similar  to  the  structure  of  the  colon,  except  that  the 
muscular  structure  is  ill  developed  and  trivial  in  amount. 
Lockwood  points  out  that  there  is  an  extensive  lymph  system 
in  the  appendix,  and  that  the  submucous  and  subperitoneal 
tissues  communicate  by  numerous  gaps  in  the  muscles.^ 
The  appendix  averages  about  four  and  a  half  inches  in 
length,  and  its  diameter  is,  as  a  rule,  about  equal  to  that  of  a 
No.  9  English  bougie  ;  its  canal  is  narrow  and  is  partly  closed 
by  the  valve  of  Gerlach  (Talamon).  The  appendix  enters 
the  cecum  at  its  posterior  internal  part,  which  is  usually  the 
seat  of  the  most  intense  pain  in  inflammation,  and  corresponds 
to  a  point  on  the  surface  two  inches  from  the  spine  of  the 
ilium,  on  a  line  drawn  from  the  umbilicus  to  the  anterior 
superior  iliac  spine,  which  is  known  as  "  McBurney's  point." 
The  free  part  of  the  appendix  in  one-third  of  all  persons  is  in 
relation  with  the  posterior  surface  of  the  cecum ;  in  almost 
one-third  of  all  persons  it  is  fixed  in  the  iliac  fossa,  so  that  if 
perforation  occurs  the  contents  will  be  voided  in  the  retro- 
peritoneal tissue  (iliac  abscess).  In  some  cases  it  is  external 
to  the  cecum  ;  in  some  it  passes  downward,  and  in  some 
inward.  It  is  important  to  remember  that  the  appendix  may 
be  met  with  in  the  most  unexpected  situations.  When  the 
ascending  colon  is  displaced  the  diverticulum  may  be  upon 
the  left  side.  It  is  not  unusual  to  find  its  tip  in  the  middle 
line,  up  toward  or  adherent  to  the  gall-bladder,  or  in  the 
pelvis.  In  about  two-thirds  of  all  cases  the  appendix  is  com- 
pletely covered  with  peritoneum ;  in  one-third  of  all  cases  it 
is  in  contact,  in  some  part  of  its  length,  with  cellular  tissue 
(Talamon).     Robinson  has  called  attention  to  the  fact  that 

1  See  R.  J.  Lee  Morrill's  article  in  the  American  Medico- Surgical  Bulletin, 
Dec.  19,  1896. 

2  British  Medical  Journal,  Jan.  27,  1900. 


.-/  PPEXDICITIS.  785 

the  appendix  is  frequently  in  contact  with  the  psoas  muscle 
in  men. 

Etiolog-y  and  Pathology. — Appendicitis   is  very  rare  in 
infants,  but  is  common  at  an>-  period  beyond  childhood,  being 
more  frequent  in  young  and  middle-aged  people  than  in  the 
aged.     Appendicitis  is  a  bacterial   disease.     It  is  produced 
occasionally  by  pus  cocci,  but  most  commonly  by  the  action 
of  the  bacterium  coli  commune  of  Escherich.     These  mi- 
crobes, which  normally  inhabit  the  appendix,  are  harmless 
when  the  appendix  is   healthy,  but  become  active  for  harm 
when  the  diverticulum  is  bruised,  obstructed^irritated  by  the 
presence  of  uric  acid,  or  congested  because  of  chilling  of  the 
cutaneous  surface  of  the  body.    When  non-traumatic  inflam- 
mation occurs  sweUing  of  the  mucous  membrane  occludes  the 
opening  into  the  colon,  and  the  lumen  of  the  appendix  dilates 
and  fills  up  with  a  thick  mucopurulent  fluid.    Ulcers  some- 
times form,  which  may  only  involve  the  mucous  membrane, 
may  pass  deeply  into  the  coats,  or  ma}'  even  perforate.    Dieu- 
lafoy^  maintains  forcefully  that  appendicitis  is  due  ahvays  to 
the  conversion  of  the  appendix  into  a  closed  cavit>',  but  cases 
are  met  with  which  disprove  this  assertion.     Various  con- 
ditions may  bring  about  this    transformation.      Partial   ob- 
struction may  be  caused  by  calculi,  which  are  composed  of 
stercoral  material  and  hordes  of  bacteria  mixed  with  salts  of 
lime  and  magnesia.     These   calculi   are   not  formed  in  the 
colon,  but  are  formed  in  the  appendix.     Dieulafoy  speaks  of 
the  condition  as  appendicular  lithiasis,  and  says  the  condition 
has  a  tendency  to  run  in  family  lines,  and  has  a  kinship  with 
gout  and  rheumatism.     Obstruction  may  be  caused  b\'  local 
infection  of  a  catarrhal  area,  by  the  formation  of  a  fibrous 
stricture,  or  by  several  causes  acting  in  unison.     The  theory 
that  concretions  form  in  the  colon,  and  are  forced  into  the 
appendix  by  peristalsis,  has  been  ver>^  largely  abandoned. 
The  presence  of  a  concretion  is  alwaj's  dangerous.     It  is  fre- 
quently associated  with  ulceration,  either  as  cause  or  effect. 
It  is  a  mass  of  virulent  bacteria.     It  may  lead  to  perforation 
or  gangrene.     Talamon  taught  that  the  appendix  resents  the 
presence  of  the  concretion,  reflex  contraction  of  the  muscu- 
lar coat  taking  place,  which  is  accompanied  by  violent  pain 
(appendicular  colic).     The  muscular  structure  is  so  rudimen- 
tary that  it  does  not  seem  probable  that  attempts  at  contrac- 
tion, even  should  they  arise,  would  produce  violent  pain  and 
distant  symptoms.     Pozzi  believes   that  appendicular    colic 
may  be  caused  by  torsion  or  bending  of  the  appendix,  or 

1  Progres  medicale.  No.  II,  1S96. 
50 


786      DISEASES  AND   INJURIES   OF   THE  ABDOMEN. 

malposition  of  the  diverticulum,  and  holds  that  pain  may 
arise  when  there  is  no  lesion  in  the  appendix  and  no  inflam- 
mation of  the  peritoneum  or  pericecal  structures/  The  term 
appendicular  colic  has  led  to  much  injudicious  conservatism, 
and,  as  Lockwood  shows,  if  an  appendix  is  removed  from  an 
individual  who  suffers  from  attacks  of  appendicular  colic,  it 
will  usually  be  found  that  the  diverticulum  is  inflamed  or  the 
lumen  contains  a  concretion.  Foreign  bodies,  such  as  pins, 
fish-bones,  nails,  buttons,  date-stones,  cherry-stones,  and 
grape-seeds,  may  enter  the  appendix,  but  they  do  so  far  less 
often  than  is  generally  supposed,  most  alleged  grape-seeds 
from  the  appendix  being  fecal  concretions.  Fitz  found  con- 
cretions in  1 5  cases  out  of  300.  Ranvier  collected  the  rec- 
ords of  459  postmortems,  and  found  reported  179  fecal  con- 
cretions and  16  foreign  bodies.  Appendicitis  due  to  a  for- 
eign body,  such  as  a  grape-seed  or  a  pin,  is  known  as 
trmmiatic  ;  appendicitis  in  which  a  concretion  is  the  assumed 
cause  is  known  as  stercoral.  A  foreign  body  may  produce 
instant  perforation.  If  impaction  of  a  foreign  body  or  con- 
cretion occurs,  the  orifice  of  the  appendix  is  closed,  the  cir- 
culation is  soon  cut  off,  the  secretions  are  retained,  the  coats 
become  congested,  the  diverticulum  enlarges  enormously, 
microbes  multiply  with  great  rapidity,  and  the  wall  of  the 
congested  appendix  inflames  and  may  become  gangrenous 
or  ulcerated,  and  is  finally  perforated.  Interference  with  the 
blood-supply  of  the  appendix  will  predispose  to  appendicitis. 
This  may  be  brought  about  by  twists,  bruises,  adhesions, 
concretions,  pressure,  or  bands  ;  and  the  psoas  muscle  may 
play  a  part  in  the  production  of  these  conditions.  In  women 
appendicitis  is  occasionally  secondary  to  tubo-ovarian  dis- 
ease. Appendicitis  is  rarer  in  women  than  in  men,  probably 
because  the  appendix  of  a  woman  has  a  better  blood-supply, 
the  additional  supply  coming  through  the  folds  of  the  appen- 
diculo-ovarian  ligament.  Catarrhal  conditions  of  the  intes- 
tine, habitual  constipation,  and  indigestion  with  flatulence  pre- 
dispose to.  appendicitis.  It  seems  probable  that  catarrhal 
appendicitis  may  result  from  extension  of  a  catarrh  of  the 
colon,  and  may  also  arise  from  external  traumatism.  If 
before  perforation  the  appendix  adheres  to  the  cellular  tissue 
behind  the  cecum,  cellulitis  or  abscess  without  peritonitis 
may  result.  When  appendicitis  goes  on  to  perforation  there 
is  always  some  peritonitis ;  but  if  the  steps  to  perforation  are 
gradual,  and  if  the  causative  organism  is  the  colon  bacillus, 
the  peritonitis  may  be  local,  and  will  sometimes  by  formation 

^  Progres  niedicale.  No.  19,  1896. 


APPEXDICITIS.  787 

of  adhesions  make  a  barrier  between  the  appendix  and  the 
peritoneal  cavity  before  perforation  occurs.  When  perfora- 
tion takes  place  suddenly  diffused  septic  peritonitis  is  inevit- 
able. When  the  causative  organism  is  the  streptococcus 
general  peritonitis  is  very  apt  to  arise.  Peritonitis  may  arise 
without  perforation  by  contiguity  of  structure  or  by  migra- 
tion of  bacteria  through  the  congested  walls  of  an  obstructed 
appendix.  In  some  cases  perforation  takes  place  into  the 
peritoneal  cavity,  but  pus  is  circumscribed  by  matting 
together  of  the  intestines  with  plastic  exudate.  The  appen- 
dix may  become  gangrenous  very  rapidly  or  after  some  time. 
A  case  of  appendicitis  in  w^hich  gangrene  and  perforation 
come  on  ver}'  quickly  is  spoken  of  as  fulminating  appendi- 
citis. In  some  cases,  if  the  perforation  is  very  small  and  the 
appendix  is  swathed  in  lymph,  or  if  perforation  does  not 
occur,  the  inflammation  may  subside.  Perforation  rarely 
occurs  from  liquid  pressure  or  from  the  pressure  of  a  concre- 
tion ;  it  is  generally  due  to  ulceration  produced  by  the  action 
of  micro-organisms.  Appendicitis  which  subsides  may  at 
any  time  recur,  and  the  life  of  the  patient  is  under  constant 
menace.  An  enormous  number  of  people  have  had  appen- 
dicitis. Toft  recorded  500  autopsies,  and  in  36  per  cent,  of 
them  there  were  positive  signs  of  past  attacks.  The  disease 
is  occasionally  unsuspected  during  life.  These  facts  prove 
that  the  disease  may  subside  without  the  aid  of  surgery. 

Forms  of  Appendicitis. — In  what  is  known  as  appoidic- 
ular  colic  the  appendix  is  temporarily  obstructed  because  of 
swelirng^f  the  mucous  membrane  of  the  outlet,  and  the 
stercoral  contents  are  retained  in  the  diverticulum.  This 
condition  is  called  by  Fergusson  "constipation  of  the  appen- 
dix." If  not  relieved,  it  will  rapid!}-  eventuate  in  appendicitis. 
It  is  an  unfortunate  term,  sometimes  used  as  an  excuse  for 
avoiding  operation.  In  such  cases  a  concretion  is  frequently 
or  usually  present. 

Sijnple  parietal  or  catan-hal  appendicitis  is  not  limited  to 
the  mucous  membrane;  hence  the  term  catarrhal  is  not 
strictly  correct.  The  vessels  of  the  appendix  are  distended 
with  blood,  the  lumen  at  the  intestinal  end  becomes  par- 
tially or  completely  obstructed,  the  epithelium  desquamates 
from  numerous  glands,  the  mucosa  ulcerates,  and  the  lumen 
of  the  appendix  becomes  filled  with  a  mixture  of  mucus, 
bacteria,  and  portions  of  organic  matter.  Bacteria  enter  the 
lymph-spaces  of  the  wall  of  the  appendix,  and  pass  rapidly 
from  the  submucous  to  the  subperitoneal  tissues.  Forty- 
eight  hours  after  the  mucous  coat  begins  to  inflame  the  peri- 


788      DISEASES  AND  INJURIES   OF   THE  ABDOMEN. 

toneal  coat  will  probably  be  involved.  This  inflammation 
may  undergo  resolution  and  the  patient  get  well  or  events 
may  result  disastrously.  Suppuration  or  gangrene  may 
occur,  perforation  may  take  place,  or  pyemia,  with  abscess  of 
the  liver,  may  arise.  The  acute  condition  may  pass  into 
chronic  appendicitis,  or  ulcerations  of  the  mucosa  may  remain ; 
the  mucous  crypts  may  be  filled  with  bacteria ;  a  concretion 
may  exist;  cicatricial  contractions  may  occur:  in  any  one  of 
these  conditions  the  patient  is  in  danger  of  a  fresh  attack 
at  any  time.  In  a  catarrhal  inflammation  secondar>^  to 
catarrh  of  the  colon  the  case  may  be  chronic  from  the  begin- 
ning. If  the  lumen  of  the  appendix  Js„^radually;  and  com- 
pletely obliterated,  the  condition  is  denominated^M/rr^/'/z'^ 
appendicitis  (Senn).  This  progressive  obliteration  may  result 
from  repeated  attacks  of  inflammation  or  may  be  simply  a 
degenerative  change.  Recurrent  appendicitis,  it  is  said,  may 
be  due  to  inordinate  size  of  the  mouth  of  the  appendix,  mak- 
ing of  this  diverticulum  a  drag-net  for  foreign  bodies;  but  it 
is  more  probable  that  it  is  due  to  smallness  of  the  opening, 
so  that  it  quickly  closes  and  converts  the  appendix  into  a 
closed  vase  filled  with  septic  material.  Suppurative  appen- 
dicitis is  due  to  purulent  infiltration  of  the  walls.  Pus  in  the 
lumen  is  not  purulent  appendicitis.  Gangrenous  appendicitis 
is  ajjtoisl^or^  septic  gangrene,  due  to  interference  with  the 
circulation  and  to  tissue-destruction  by  the  action  of  micro- 
organisms. Perforations  occur,  and  they  are  often  multiple. 
The  entire  appendix  may  slough  off.  Interference  with  cir- 
culation may  be  caused  by  an  obstruction,  by  a  bend,  or 
twist,  or  bruise  of  the  appendix,  or  by  the  action  of  virulent 
organisms  on  an  appendix  whose  tissue-resistance  is  lowered 
by  injury  or  disease.  In  gangrenous  cases  the  vessels  of  the 
meso-appendix  are  usually  obstructed  by  thrombi  or  the 
changes  of  arteritis  (Van  Cott). 

Fowler  suggests  the  following  classification  of  cases  of 
appendicitis  :  (i)  endo-appendicitis  ;  (2)  parietal  appendicitis  ; 
(3)  peri-appendicitis ;    (4)  para-appendicitis. 

As  a  matter  of  fact,  appendicitis  is  always  one  disease, 
which  varies  in  intensity,  and  it  is  useless  to  divide  it  into  a 
great  number  of  symptomatic  groups.  In  rare  instances 
appendicitis  is  due  to  tubercular  ulceration,  in  other  cases  to 
typhoid  ulceration,  and  genuine  appendicitis  may  arise  during 
typhoid  fever. 

Symptoms. — In  what  is  known  as  appendicular  coHc  the 
patient  suffers  from  disorder  of  digestion  and  occasionally 
has  a  brief  attack  of  abdominal  pain  associated  with  trivial 


APPENDICITIS.  789 

and  temporary  tenderness  in  the  right  ihac  fossa.  The  col- 
icky pain  is  about  the  umbilicus  and  right  iliac  fossa;  there  is 
often  nausea  and  usually  constipation.  This  condition,  if  not 
soon  reliev^ed,  is  followed  by  the  evidences  of  inflammation. 
The  symptoms  of  genuine  appendicitis  are  as  follows :  in 
some  cases  the  patient  feels  out  of  sorts  for  a  day  or  two  ;  in 
others  the  trouble  seems  to  begin  suddenly.  Constipation  is 
ver}'  generally  present,  but  in  rare  cases  there  is  diarrhea. 
The  sufferer  complains  of  anorexia,  dyspepsia,  flatulence,  col- 
icky pain  about  the  umbilicus,  and  later  a  feeling  of  weight, 
soreness,  or  pain  in  the  right  iliac  fossa.  Nausea  is  often 
present,  and  vomiting  may  occur.  The  tongue  is  coated. 
Examination  discovers  tenderness,  rigidity,  fulness,  and  pain 
in  the  right  iliac  fossa.  The  tenderness  is  most  marked  about 
McBurney's  point.  There  is  usually  moderate  fever,  and  the 
pulse  as  a  rule  is  about  lOO,  but  may  be  less  or  more  than  this. 
The  patient  may  gat  well,  the  symptoms  gradually  passing  off 
He  may  get  rapidly  or  gradually  worse.  If  he  becomes  worse, 
the  tenderness  increases  ;  the  pain  becomes  agonizing  and 
radiates  toward  the  umbilicus,  and  the  patient  draws  up  the 
right  leg  to  relieve  it.  Pressure  upon  the  left  side  often 
causes  pain  in  the  right  iliac  region.  The  pulse  increases  in 
frequency,  the  fever  usually  rises,  the  abdominal  distention 
and  rigidity  become  more  marked,  vomiting  begins  and 
becomes  worse,  and  the  respiration  becomes  shallow  and 
thoracic.  There  are  great  thirst,  anorexia,  constipation,  and 
mental  anxiety.  Absolute  intestinal  obstruction  sometimes 
takes  place.  The  urine  is  scanty  and  highly,  colored.  Hic^ 
coughs-  develop.  If  the  inflammation  continues  for  one  or 
two  days,  swelling  is  often  observed  in  the  right  iliac  fossa, 
or  is  detected  by  a  vaginal  or  rectal  examination,  or  by 
bimanual  palpation,  or  by  examination  under  ether.  It  is 
not  wise  to  forcibly  palpate  in  acute  appendicitis,  as  it  may 
cause  rupture.  If  the  appendix  is  enlarged,  and  the  indi- 
vidual has  a  thin  abdomen  which  is  not  rigid,  it  is  often  pos- 
sible to  palpate  the  appendix.  Sometimes  it  may  be  felt 
when  the  patient  is  anesthetized,  though  it  could  not  be 
detected  before. 

A  case  of  appendicitis  may  come  on  suddenly  with  pain,  pre- 
monitory symptoms  having  never  occurred.  There  are  nausea 
and  bilious  vomiting,  constipation,  and  distention  of  the  abdo- 
men. Such  attacks  are  not  to  be  considered  as  colic  from 
the  presence  of  a  calculus.  They  are  inflammatory,  and  are 
associated  with  fever  and  the  other  symptoms  previously 
set  forth.     Examination  detects  tenderness  in  the  right  iliac 


790      DISEASES  AND   INJURIES   OF  THE  ABDOMEN. 

fossa.  The  point  of  greatest  tenderness  is  known  as  "  Mc- 
Burney's  point."  This  is  apt  to  be  about  two  inches  from 
the  anterior  superior  spine  of  the  ilium,  on  a  line  drawn  from 
the  spine  to  the  umbilicus.  Pain  at  McBurney's  point  is 
linked  with  local  muscular  rigidity  and  hyperesthesia  of  skin. 
Such  a  case,  like  the  former  cases  described,  may  get  well  or 
may  get  worse.  In  some  cases  all  the  symptoms  are  violent 
from  the  beginning,  the  attack  tends  to  Hnger,  and  is  followed 
by  persistent  soreness  of  the  appendix  and  harassing  digestive 
disturbances.  Any  case  of  appendicitis  may  become  suddenly 
desperately  grave  because  of  perforation  or  gangrene.  The 
temperature  falls,  hiccough  begins,  abdominal  distention,  pain, 
and  tenderness  become  marked  and  general,  and  the  pulse 
becomes  very  rapid.  In  some  cases  these  grave  symptoms 
are  present  almost  from  the  start  (fulminating  cases).  A  sud- 
den perforation  produces  collapse,  and,  if  reaction  takes  place, 
general  peritonitis  arises.  Peritonitis,  be  it  remembered,  may 
arise  without  either  perforation  or  gangrene.  If  pus  forms, 
it  may  be  unlimited  by  adhesion.  In  such  cases  there  is  the 
rapid  onset  of  fatal  peritonitis  and  septicemia.  Pus  may  be 
limited  by  adhesions  and  be  practically  extraperitoneal.  In 
such  a  case  a  lump  is  felt  in  the  right  iliac  region  ;  and  dusky 
discoloration  and  edema  of  skin  sometimes  exist.  In  an  ab- 
scess case  there  are  usually  irregular  fever  and  sweating.  A 
limited  collection  of  pus  may  be  liberated  into  the  peritoneal 
cavity  by  rupture  of  the  abscess-wall.  Such  a  rupture  may 
be  caused  by  pressure  or  muscular  effort ;  rupture  is  followed 
at  once  by  shock  and  later  by  diffused  peritonitis.  An 
abscess  may  rupture  externally,  or  into  the  vagina,  intes- 
tinal tract,  or  bladder.  It  is  desirable,  if  possible,  to  locate 
the  situation  of  the  appendix,  and  this  is  usually  deter- 
mined by  locating  the  seat  of  swelling  and  of  greatest  ten- 
derness. The  surgeon  should  not  lose  sight  of  the  fact 
that  the  appendix  may  be  found  in  the  most  unexpected 
situations.  In  every  case  a  rectal  or  vaginal  examination 
should  be  made,  in  order  to  detect  swelling  and  tenderness, 
and  thus  determine  if  the  inflammation  took  origin  in  or 
has  come  to  involve  the  pelvic  region.  Pain  at  the  end  of 
micturition  points  to  involvement  of  the  vesical  peritoneum.^ 
In  cases  where  there  is  not  localized  swelling  and  tenderness, 
as  in  gangrenous  or  perforative  appendicitis  with  general  peri- 
tonitis, "  diagnostic  localization  "  is  impossible  (Van  Hook). 

Terminations. — Appendicitis  may  terminate  in  complete 
recovery,  in    death,  or   m  "a   condition    of    lowered    vitality, 

1  Van  Hook,  'n\  Jotir.  Am.  Med.  Assoc,  Feb.  20,  1897. 


APPENDICITIS.  791 

during  the  existence  of  which  acute  attacks  are  almost  cer- 
tain to  occur.  Adhesions  may  form  as  a  result  of  appen- 
dicitis, general  peritonitis  may  arise,  the  appendix  may  slough 
or  become  perforated,  or  abscess  may  ensue  upon  local  peri- 
tonitis. Lymphangitis  of  the  ajjpendix  may  accompany,  and 
septic  phlebitis  and  abscess  of  the  liver  may  follow,  appen- 
dicitis! ~~ii^'a  patient  has  once  had  appendicitis,  he  will  always 
be4iable  to  sutler  from  another  attack  if  the  appendix  has  not 
been  removed.  The  liability  becomes  almost  a  certainty  if 
the  intestinal  end  of  the  appendix  is  narrowed  or  if  the 
lumen  is  obstructed  at  any  point,  if  a  concretion  exists, 
or  if  there  is  an  area  of  ulceration  or  of  desquamating  epi- 
thelium. After  an  attack  the  appendix  ma}'  remain  enlarged 
and  tender ;  exercise  or  indiscretion  in  diet  may  cause  it  to 
become  tender,  or  the  patient  may  have  occasional  attacks 
of  colicky  pain.  If  any  of  the  above  conditions  exist,  another 
attack  may  be  confidently  anticipated  if  operation  is  not  per- 
formed. In  such  cases  the  appendix  can  usually  be  palpated. 
The  method  of  palpation  proposed  by  Robert  T.  Morris  is 
very  useful.^     It  is  applied  as  follows  : 

The  surgeon  stands  to  the  right  of  the  patient  and  uses 
three  fingers  of  the  right  hand  to  feel  with  and  three  fingers 
of  the  left  hand  to  press  with.  Morris  insists  that  no  mus- 
cular effort  should  be  used  by  the  hand  which  feels.  The 
feeling  fingers  are  pressed  by  the  other  fingers  beneath  the  mar- 
gin of  the  right  rectus  muscle  on  a  level  with  the  umbilicus, 
and  are  drawn  toward  the  patient's  right  side,  and  the  colon 
will  be  felt  to  roll  under  the  fingers.  The  process  is  repeated 
several  times  until  the  end  of  the  cecum  is  reached.  The 
appendix  is  sought  for  by  rolling  the  cecum  from  side  to 
side  with  the  finger-tips,  and  working  toward  the  proximal 
end  of  the  appendix.^ 

Diag-nosis.— The  diagnosis  is  not  invariably  so  certain 
as  we  might  assume  from  some  writings.  Appendicitis 
may  be  difficult  to  diagnosticate  from  typhoid  fever;  sup- 
puration or  twisting  of  the  pedicle  of  an  ovarian  cyst ; 
extra-uterine  pregnancy;  stone  in  the  kidney  or  ureter;  em- 
pyema of  the  gall-bladder  ;    hepatic  colic  ;    movable  kidney  ; 

and,  if  the  appendix  lies  posterior  and  against  the  outer  layer     - 1 

of  the  mesocolon,  perinephric  abscess:  <tvvcti..i  .^c*/,  •  h       v  ^v^*^■<■^'",*^ 

Treatment. — If  the  diagnosis  were  always  certain  from  the  ^^^"iu.t^ 
beginning,  and  if  the  cases  were  seen  at  the  vet}'  start  b}-  a 
surgeon,  immediate  operation  in  e\ery  case  would  be  emi- 

1  See  Medical  Record,  Sept.  17.  1898. 

^  Robert  T.  Morris,  in  Medical  Record,  Sept.  17,  1898. 


792      DISEASES  AND  INJURIES   OF   THE  ABDOMEN. 

nently  proper.  If  this  plan  could  be  followed,  the  mortality 
from  appendicitis  would  be  extremely  small.  At  this  early 
stage  the  peritoneum  is  free  from  infection,  and  the  appendix 
can  be  rapidly  and  easily  removed  without  risk  of  infecting 
the  peritoneum.  Unfortunately,  this  plan  cannot  be  habit- 
ually followed.  As  a  rule,  when  the  physician  first  sees  the 
case  the  appendicular  peritoneum  is  inflamed,  and  the  surgeon 
usually  sees  the  case  at  even  a  later  period  than  the  physi- 
cian. At  this  time  the  barriers  of  leukocytes  are  being 
heaped  up  to  limit  the  spread  of  infection,  and  delicate  en- 
compassing adhesions  are  usually  being  formed.  Operation 
at  this  stage  may  be  imperatively  necessary,  because  of  the 
rapid  spread  and  dangerous  nature  of  the  process ;  but  when 
operation  is  not  done,  in  most  cases  at  least  a  temporary 
limitation  will  be  secured  and  the  case  will  go  on  to  an  inter- 
val. Operation  in  this  period  is  always  dangerous;  opera- 
tion in  an  interval  is  safe.  In  many  instances  it  is  wiser  to 
avoid  operating  when  the  case  is  first  seen,  and  it  is  proper 
to  wait  for  an  interval.  The  period  in  which  the  surgeon 
usually  sees  the  case  for  the  first  time  is  said  by  McBurney 
to  be  "  too  late  for  an  early  operation  and  too  early  for  a 
late  operation."  Those  who  say,  "  operate  as  soon  as  the 
diagnosis  is  made,"  operate  as  a  rule  in  this  dangerous 
period,  and  in  this  period  I  do  not  believe  that  every  case 
should  be  promptly  cut.  Many  cases,  it  is  true,  must  be 
operated  on  as  soon  as  seen,  irrespective  of  the  duration 
of  the  disease.  X^^  must  operate  promptly  if  the  pulse  is 
small  and  well  above  lOO;  if  there  is  persistent  vomiting; 
if  there  is  delirium ;  if  intestinal  obstruction  exists  ;  if  a  chill 
has  occurred  ;  if  the  pain  and  rigidity  are  very  marked  ;  if  a 
mass  can  be  felt  in  the  right  iliac  fossa  or  by  rectal  exami- 
nation ;  if  there  is  marked  abdominal  distention ;  if  there  are 
evidences  of  pus  formation ;  if  the  patient  is  growing  worse ; 
if  there  is  or  has  been  shock  ;  or  if  the  pain  suddenly  passes 
away  without  tlie_  use  of  opiates. 

In  an  ordinary  mild  case,  in  which  none  of  the  above 
named  conditions  or  symptoms  exist,  it  is  best  to  defer 
operation.  Those  who  advocate  operating  upon  every  case 
consider  such  delay  reprehensible  and  dangerous,  point  out 
that  even  in  apparently  mild  cases  gangrene  or  perforation 
may  quickly  occur,  and  cite  striking  cases  to  emphasize  their 
belief.  There  is  much  force  in  this  view  and  it  must  not  be 
hastily  rejected.  The  choice.  However,  is  not  between  a 
dangerous  delay  and  a  safe  operation,  but  is  rather  between  a 
dangerous  delay  and  a  dangerous  operation.     It  is  a  question 


APPEXDICITIS.  793 

of  two  dangers,  and  each  side  chooses  the  danger  which 
seems  to  it  the  least.  Richardson's  elaborate  study  of  750 
cases,  showing  a  mortalit}'  of  18  per  cent,  in  operations  for 
acute  appendicitis,  determines  us  in  the  practice  of  the  more 
conservative  plan. 

In  an  ordinary  mild  case  of  appendicitis  the  patient  is 
purged  by  means  of  Epsom  or  Rochelle  salt.  This  prac- 
tice was  begun  because  of  the  belief  that  inflammation  of  the 
appendix  is  associated  with  fecal  impaction  in  the  head  of  the 
colon.  This  belief  has  been  exploded,  but  the  treatment  is 
still  used,  because  experience  shows  that  it  is  beneficial.  If 
the  condition  of  the  stomach  prevents  the  administration  of 
salines,  high  enemas  should  be  given. 

Opium  is  ne\-er  given.  In  the  first  place,  it  is  not  needed, 
foiMtthe  ^ain  is  so  violent  as  to  absolutely  demand  opium, 
operation  should  be  performed.  In  the  second  place,  opium 
masks  the  symptoms,  makes  the  patient  feel  comfortable,  and 
gives  the  physician  an  unfortunate  and  ill-founded  sense  of 
security.  The  pain  about  the  umbilicus,  if  severe,  can  be 
distinctly  and  safely  relie\"ed,  b\^  the  administration  of  thirty 
minims  of  chloroform  ever}'  half  hour  until  three  doses 
are  taken.  When  tenderness  can  be  demonstrated  in  the 
right  iliac  fossa  an  ice-bag  should  be  applied. 

The  case  should  be  seen  a^ain  witly'n.-si'^-  h'^nrs  We  are 
accustomed  to  follow  ]\IcBurney's  rule,  which  is  as  follows  : 
If  on  seeing  the  patient  again,  six  hours  after  the  first  visit, 
the  patient  is  worse,  operate  at  once.  If  he  is  no  worse, 
there  is  no  pressing  danger. 

If  in  twelve  hours  after  the  beginning  of  the  attack  the 
symptoms  are  not  intensified,  they  will  soon  begin  to  abate  ; 
it  the  symptoms  have  become  w^orse  during  this  time, 
operate.  If  in  twent}'-four  hours  after  the  beginning  of 
the  attack  the  severity  of  the  symptoms  lessens,  if  is  usually 
possible  to  wait  for  an  interval ;  but  if  during  the  second 
twent}--four  hours  the  abatement  in  the  severit}'  of  symptoms 
has  not  gone  on  and  there  is  doubt  as  to  the  condition, 
operate  at  once.^  If  operation  is  not  performed,  the  patient 
is  restricted  to  a  liquid  diet  and  the  bowels  are  moved  daily 
by  salines. 

If  pus  is  present,  some  surgeons  delay  operation  in  the 
hope  that  firm  adhesions  will  form  around  the  pus,  and 
that  the  necessary  operation  will  simply  be  the  opening  of 
an  abscess.  I  do  not  believe  it  is  safe  to  delay  operation 
in  a  pus  case.     The    pus  may  become  limited,  but  it  may 

^  For  McBurney's  views,  see  A*.   Y.  Polyclinic,  January  15,  1897. 


794    BfSEASES  AND   INJURIES   OF  THE  ABDOMEN. 

instead  pass  up  toward  the  liver  or  down  into  the  pelvis. 
Delay  is  fraught  with  peril. 

When  the  attack  has  subsided,  and  about  three  weeks 
or  more  have  passed,  the  appendix  can  be  removed  with 
remarkable  safety.  After  a  patient  has  had  two  or  more 
attacks  of  appendicitis  all  surgeons  agree  that  the  appendix 
should  be  removed. 

If  only  one  attack  has  occurred,  there  may  never  be 
another,  and  the  question  arises.  Should  the  appendix  be 
removed  after  one  attack  ?  We  do  not  know  that  a  man  has 
really  recovered  after  purely  medical  treatment.  Many  cases 
reported  as  cured  by  medical  means  have  subsequently 
required  operation.  As  Lockwood  puts  it/  "  To  say  that  a 
man  with  appendicitis  has  been  cured  by  medical  means  is  in 
many  cases  equivalent  to  saying  that  a  man  with  a  stone  in 
his  bladder  has  recovered  from  calculus  after  the  cure  of  a 
cystitis  by  rest  in  bed." 

After  a  first  attack  if  the  appendix  remains  tender  or 
becomes  tender  after  exercise,  or  if  attacks  of  colicky  pain 
occur,  operate. 

In  some  cases  a  single  attack  of  appendicitis  is  followed  by 
persistent  dyspepsia  and  ill  health,  and  in  such  cases  operation 
should  be  performed.  In  the  majority  of  cases,  after  even 
one  well-marked  attack,  operation  is  necessary  (see  Operation 
for  Appendicitis). 

i^nteroptosis,  or  Glenard's  Disease. — This  disease  is 
a  prolapse  of  the  intestine.  It  may  be  but  a  part  of  ptosis 
or  prolapse  of  all  the  abdominal  viscera  ;  it  may  exist  alone ; 
it  may  be  associated  with  movable  kidney,  prolapse  of  the 
stomach  (gastroptosis),  of  the  liver  (hepataptosis),  or  of  the 
spleen  (splenoptosis). 

In  Glenard's  disease  the  intestines  occupy  the  lower  por- 
tion of  the  abdomen,  and  the  belly  below  the  costal  margins 
is  flat,  is  dull  on  percussion,  and  the  pulsations  of  the  aorta 
are  very  evident.  The  right  portion  of  the  transverse  colon 
begins  to  descend  first,  and  other  portions  of  the  intestine 
follow.  The  victims  of  this  disease  are  dyspeptic,  anemic, 
and  neurasthenic.  The  condition  may  arise  without  apparent 
cause,  may  be  caused  by  wearing  corsets,  by  falls,  by  blows, 
by  lifting  heavy  weights,  and  by  prolonged  vomiting.  The 
dyspepsia  is  due  to  dragging  on  the  duodenum,  the  tube 
becoming  flattened  out  (A.  K.  Stone).  The  flattening  of  the 
duodenum  may  be  followed  by  kinking  of  the  pylorus,  and 
in  such  a  case  the  stomach  dilates,  otherwise  it  is  not  dilated. 

'  Bi'it.  Med.  Jour.,  January  27,  1900. 


ACUTE   PERITOXITIS.  795 

Treatment  is  medical  unless  the  kidney,  liver,  or  spleen 
is  mo\able.  Employ  lavage,  order  a  proper  abdominal 
support,  insist  on  regular  exercise,  and  treat  the  anemia  and 
dyspepsia. 

The  Peritoneum. 

Acute  Peritonitis. — Peritonitis,  or  inflammation  of  the 
peritoneum,  is  a  common  and  important  disease. 

Aseptic  irritation  by  a  traumatism  or  a  chemical  irritant, 
produces  aseptic  peritonitis,  a  condition  which  is  strictly  lim- 
ited ;  which  may  produce  local  pain  and  tenderness  ;  which 
may  cause  aseptic  fever  from  the  absorption  of  fibrin-ferment 
and  the  products  of  tissue-change ;  which  leads  to  the  forma- 
tion of  temporary  or  permanent  adhesions,  and  which  is,  in 
realitv,  a  process  of  repair. 

Peritonitis,  as  the  term  is  used  by  the  surgeon,  is  always 
due  to  bacteria.     Bacteria  may  reach  the  peritoneal  cavity  by 
means  of  an  abdominal  wound  or  the  entrance  of  foreign 
bodies  ;  by   extravasations   from  the  stomach,  bowel,  vermi- 
form appendix,  gall-bladder,  urinarj-  bladder,  kidney,  Fallo- 
pian tube,  or  uterus,  or  by  the  passage  of  micro-organisms 
through  the  damaged  walls  of  any  of  these  viscera  or  struct- 
ures ;%y  way  of  an  open  Fallopian  tube  ;  from  the  break- 
ing of  an  abscess  into  the  peritoneal  cavity ;  from  areas  of 
ne1;rosis  due  to  volvulus,  strangulation,  or  intussusception  of 
the  intestine ;  twisting  of  the  pedicle  of  an  ovarian  tumor,  a 
floating  kidnev,  or  a  floating  spleen ;  blocking  of  a  mesen- 
teric vessel  bv  a  thrombus  or  an  embolism  ;  gangrene  of  the 
pancreas    or 'spleen,  and  fat-necrosis.'      In  some  cages  the 
peritoneum  may  contain  a  point  of  least  resistance,  and  bac- 
teria contained  in  the  blood  reach  this  point  and  produce 
infection.     It  used  to  be  thought  that  cold  could  produce 
peritonitis,  but  it  seems  probable  that  it  can  only  act  by  pro- 
ducing an  area  of  least  resistance.     The  capacity  of  the  rheu- 
matic poison  to  produce  peritonitis  is  doubtful. 

The  peritoneum  is  in  reality  a  great  lymph-sac,  and,  as 
Fowler  points  out,  peritonitis  is  lymphangitis.  "  When  the 
peritoneum  is  infected  the  lymphatics  furnish  an  exudate 
which  clots  in  the  lymph-channels,  blocks  them,  and  limits 
or  prevents  absorption.  This  blocking  of  the  lymph-chan- 
nels serves  to  preser\-e  the  life  of  the  subject,  on  the  one 
hand ;  while  a  failure  in  this  respect,  either  because  of  the 
enornious  and  overwhelmingly  rapid  increase  of  septic  mate- 
rial and  the  large  size  and  number  of  channels  necessary  to 

1  See  Park's  Surgery  by  American  Authors. 


796      DISEASES  AND   INJURIES   OF  THE  ABDOMEN. 

destroy  and  obstruct,  on  the  other  hand,  permits  the  destruc- 
tion of  the  organism."^  Absorption  takes  place  most 
actively  from  the  region  of  the  diaphragm,  hence  a  perito- 
nitis in  this  region  is  peculiarly  fatal.  Absorption  takes  place 
very  rapidly  from  the  intestinal  region,  although  not  quite  so 
quickly  as  from  the  diaphragmatic  area.  Absorption  takes 
place  slowly  from  the  pelvic  region,  hence  peritonitis  of  this 
region  is  much  less  dangerous  than  is  the  disease  in  the 
intestinal  region,  and  vastly  less  dangerous  than  is  the  disease 
in  the  diaphragmatic  region  (Fowler). 

Various  bacteria  may  be  responsible  for  peritonitis,  espe- 
cially staphylococci,  streptococci,  pneumococci,  and  colon 
bacilli.  The  infections  which  spread  most  rapidly  and  widely 
are  due  to  streptococci.  In  streptococcus  infection  the  pro- 
tective exudate  does  not  coagulate,  barriers  of  leukocytes 
are  not  heaped  up,  encompassing  adhesions  do  not  form, 
there  is  rapid  absorption  of  toxins,  and  overwhelming  sys- 
temic poisoning.  Colon  bacilli  cause  a  very  grave  form  of 
peritonitis,  but  less  rapid  and  diffuse  than  that  caused  by 
streptococci — in  fact,  the  process  is  often  encompassed  for  a 
time  by  coagulated  lymph,  leukocytes,  and  adhesions.  The 
omentum  particularly  is  thickened,  and  is  apt  to  apply  itself 
about  the  area  of  infection.  Staphylococci  and  pneumo- 
cocci produce  peritonitis  which  is  more  apt  to  be  limited  than 
that  produced  by  colon  bacilli.  In  most  cases  of  peritonitis  a 
mixed  infection  exists ;  for  instance,  colon  bacilli  and  staphylo- 
cocci or  colon  bacilli  and  streptococci.  In  some  apparently 
severe  cases  of  acute  peritonitis  cultures  have  remained  sterile. 

Perms  of  Peritonitis. — An  accurate  bacteriological  clas- 
sification is  not  as  yet  possible. 

Peritonitis  can  be  named,  according  to  regions,  pelvic,  sub- 
diaphragmatic, etc. ;  it  can  be  divided  pathologically  into 
diffuse  septic,  putrid,  hemorrhagic,  suppurative,  serous,  and 
fibrinoplastic  (Senn) ;  it  can  be  classified,  etiologically,  into 
traumatic,  puerperal,  perforative,  metastatic,  etc. ;  and  it  can 
be  divided,  clinically,  into  circumscribed  suppurative,  general 
suppurative,  and  diffuse  septic. 

Circumscribed  Suppurative  Peritonitis. — In  this  condi- 
tion, which  is  frequently  met  with  in  appendicitis,  the  area 
of  infection  is  circumscribed  by  coagulated  exudate,  leuko- 
cytes, and  adhesions,  and  an  abscess  forms.  After  a  time 
distinct  localization  becomes  evident. 

The    symptoms  of  circumscribed  peritonitis    are    pain,  at 

'  George  R.  Fowler,  "  Diffuse  Septic  Peritonitis,"  in  Aledical  Record,  April 
14,  1900. 


PERITONITIS.  797 

first  general  and  then  local,  tenderness  in  a  particular  region, 
muscular  rigidity,  distention,  vomiting,  rapid  and  often  wiry 
pulse,  constipation,  fever,  great  weakness,  and  dorsal  decubitus 
with  the  thighs  flexed.  After  a  time  a  distinct  mass  can 
usually  be  detected  by  palpation,  and  there  may  be  dulness 
on  percussion,  local  rigidity,  irregular  temperature,  sweats, 
and  possibly  edema  of  the  belly-wall.  An  abscess,  though 
limited  for  a  time,  is  always  liable  to  break  through  its 
walls  and  produce  general  peritonitis.  Such  an  accident 
may  be  produced  by  muscular  effort  on  the  part  of  the 
patient  or  by  injudicious  palpation  on  the  part  of  the  surgeon; 
its  occurrence  is  announced  by  shock,  and  the  symptoms  of 
general  peritonitis  quickly  arise. 

Diffuse  septic  peritonitis  is  apt  to  destroy  life  even 
before  the  peritoneum  presents  any  marked  change.  Death 
ensues  from  the  absorption  of  toxic  alkaloids.  Septic  peri- 
tonitis may  arise  during  puerperality,  through  lymphatic 
infection;  it  may  be  due  to  infection  from  without  by  an 
operation  or  an  accident ;  to  perforation  of  an  ulcer ;  to  gan- 
grene of  a  portion  of  the  intestine ;  to  rupture  of  an  abscess 
into  the  peritoneal  cavity ;  or  to  migration  of  micro-organ- 
isms through  a  damaged  wall  of  the  bowel.  Peritonitis  due 
to  perforation  is  called  perforative  peritonitis.  Perforation 
is  made  manifest  by  a  chill,  shock,  or  rapid  collapse.  Gas 
may  pass  into  the  peritoneal  cavity,  and  if  it  does  so  the  area 
of  liver-dulness  is  lessened  or  abolished.  In  true  tympanites 
the  liver  is  pushed  up,  but  the  area  of  dulness,  though  altered 
in  position,  is  not  decidedly  lessened ;  symptoms  and  signs  of 
hemorrhage  may  arise.  Diffuse  peritonitis  is  announced  by 
a  very  rapid  pulse,  which  is  at  first  wiry  and  later  gaseous ; 
a  temperature  which  may  be  at  times  febrile,  but  which  is 
apt  to  be  subnormal  or  which  soon  becomes  so;  pain,  ten- 
derness, dry  tongue,  delirium,  persistent  vomiting,  constipa- 
tion, and  collapse.  Rigidity  may  exist,  and  also  intestinal 
obstruction  ;  often,  but  not  invariably,  there  is  distention.  In 
puerperal  peritonitis  or  septic  peritonitis  from  operation  there 
is  often  no  severe  pain ;  in  perforative  peritonitis  there  is 
acute  pain.     Patients  usually  die  within  five  or  six  days. 

Diffuse  suppurative  peritonitis  differs  clinically  from 
diffuse  septic  peritonitis  in  the  fact  that  it  is  less  apt  to  be 
fatal  and  widespread.  In  fact,  adhesions  may  form  about  an 
area  representing  a  considerable  portion  of^  the  peritoneal 
cavity.  The  causes  of  both  are  identical.  In  septic  perito- 
nitis death  occurs  from  absorption  of  toxins  before  obvious 
pathological  changes  occur  in  the  peritoneum  ;  in  suppura- 


798      DISEASES  AND   INJURIES   OF  THE  ABDOMEN. 

tive  peritonitis  the  microbes  are  fewer,  are  less  virulent,  or 
vital  resistance  is  more  decided,  and  suppuration  follows 
marked  changes  in  the  peritoneum.  In  suppurative  perito- 
nitis the  pyogenic  bacteria  are  always  present,  and  there 
exists  in  the  peritoneum  a  wound  or  damaged  area  to  consti- 
tute a  point  of  least  resistance. 

Symptoms. — Chilliness  or  a  rigor  is  common,  followed  by 
fever,  the  temperature  rising  to  102°  or  104°  F. ;  pain  is  intense, 
and  is  accentuated  by  motion  and  pressure;  the  attitude  of 
the  patient  is  assumed  to  relieve  pain  (he  lies  upon  his  back, 
with  the  shoulders  raised  and  the  thighs  drawn  up) ;  there 
are  vomiting,  obstinate  constipation,  and  rigidity  of  the 
abdominal  walls,  followed  by  distention  when  the  intestine 
becomes  paretic  from  septic  poisoning.  The  pulse  is  rapid  ; 
is  at  first  wiry,  but  may  become  gaseous.  The  constipation 
may  be  due  either  to  tympanitic  distention  or  to  the  shock 
and  toxemia  inhibiting  intestinal  peristalsis.  Vomiting  is 
frequent.  In  perforation  gas  often  passes  into  the  peritoneal 
cavity  and  obscures  the  liver-dulness  ;  in  tympanites  without 
perforation  the  liver  is  pushed  up  and  its  dulness  usually 
remains,  but  on  a  higher  level.  Pus  unconfined  by  adhe- 
sions will  gravitate  to  the  most  dependent  part  of  the  perito- 
neal cavity.  In  some  cases  of  suppurative  peritonitis  there 
is  no  tympanitic  distention  or  rigidity ;  in  some  cases  there 
is  no  fever,  and  a  subnormal  temperature  may  even  exist. 

Treatme7it. — In  the  beginning  of  ordinary  peritonitis  with- 
out perforation  give  a  saline  cathartic,  which  will  empty 
the  peritoneal  cavity  of  fluid,  will  favor  the  elimination  of 
microbes,  and  wall  combat  inflammation.  The  old-time 
remedy  was  opium,  but  Tait  proved  its  inefficiency,  and  showed 
that  it  masked  the  symptoms  and  often  created  a  false  sense 
of  security  in  the  very  midst  of  imminent  dangers.  The  usual 
method  of  administering  salines  is  to  give  3j  of  Rochelle  salt 
and  .oj  of  Epsom  salt  every  hour  until  a  free  movement 
occurs.  This  treatment  will  often  cut  short  a  beginning 
peritonitis,  and  will  frequently  prevent  a  peritonitis  after  an 
abdominal  operation.  Administer  an  enema  of  turpentine 
at  the  time  the  first  dose  of  the  saline  is  given.  If  this 
treatment  fails,  open  the  belly,  explore  for  the  causative 
condition,  remedy  it,  if  possible,  wipe  an  infected  area,  flush 
with  gallons  of  hot  salt  solution,  and  drain.  In  perforative 
peritonitis  operate,  do  not  give  cathartics  :  they  will  only 
increase  the  extravasation  and  prevent  its  limitation  by  lymph.- 
In  typhoid  fever  it  may  be  possible  to  anticipate  perforation 
by  the  occurrence  of  leukocytosis.     As  soon  as  the  patient 


PERITONITIS.  799 

has  reacted  from  the  shock  of  the  perforation  perform  a 
laparotomy,  suture  the  perforation,  wipe  and  flush  out  the 
belly,  and  drain.  In  cleansing,  give  special  attention  to 
Douglas's  pouch,  and  to  the  space  between  the  liver  and 
diaphragm.  In  diffuse  septic  peritonitis  open  the  abdomen  in 
the  middle  line,  explore  for  the  source  of  trouble,  and,  if 
possible,  remove  it.  Make  an  additional  incision  in  the 
suprapubic  region  or  through  the  right  kidney  pouch,  or  in  the 
opposite  side  of  the  abdomen.  It  is  frequently  advisable  to 
leave  the  abdominal  wound  open,  and  insert  in  it  a  piece 
of  iodoform  gauze.  Flush  with  hot  salt  solution  and  drain. 
Some  surgeons  eviscerate  and  wipe  the  intestines  with  moist 
gauze  pads.  A  circumscribed  abscess  is  treated  as  follows  : 
Open  the  abscess.  It  will  be  possible,  if  the  abscess  is  ad- 
herent to  the  abdominal  wall,  to  open  the  abscess  directly 
without  opening  the  peritoneal  cavity.  If  this  is  not  pos- 
sible, after  opening  the  abdominal  cavity  pack  gauze  pads 
in  such  a  manner  about  the  abscess  as  to  prevent  the  diffu- 
sion of  pus  when  the  abscess  is  evacuated.  After  opening 
the  abscess  the  primary  lesion  is  sought  for  and,  if  possible, 
removed.  The  surgeon  should  not,  in  most  cases,  tear  the 
lymph-barriers  in  an  attempt  to  find  the  primary  lesion,  but 
should  rather  let  it  go  undiscovered.  Pack  iodoform  gauze 
against  the  intestines  to  reinforce  the  barrier  of  lymph  and 
insert  a  tube.  It  is  frequently  advisable  to  leave  the  wounds 
open  and  drain  with  iodoform  gauze.  Every  patient  with 
peritonitis  requires  stimulants  and  frequent  feeding  with 
liquid  food. 

Tubercular  peritonitis  is  seen  by  the  surgeon  as  a  pri- 
mary local  tuberculosis,  though  it  occurs  also  as  an  associate 
of  phthisis  and  as  a  part  of  a  general  tuberculosis.  Tubercular 
peritonitis  may  be  only  a  part  of  acute  miliary  tuberculosis. 
Peritoneal  infection  may  follow  a  tubercular  lesion  of  the  in- 
testine, the  bacteria  may  enter  by  way  of  the  Fallopian  tube,  the 
initial  lesion  may  be  tubercular  appendicitis  or  tuberculosis 
of  the  mesenteric  glands.  The  germ  may  enter  in  the  blood 
or  lymph.  There  are  two  groups  of  cases,  the  common 
chronic  form  and  the  rare  acute  condition.  The  acute  form 
begins  suddenly,  and  such  cases,  as  pointed  out  by  Lejars, 
resemble  acute  appendicitis.  In  either  the  acute  or  chronic 
condition  it  is  frequently  the  case  that  pulmonary  phthisis  ex- 
ists. There  are  three  forms  of  chronic  tubercular  peritonitis  : 
the  ascitic,  the  fibrinoplastic,  and  the  caseous,^  although  as  a 
matter  of  fact  these  so-called  forms  are  only  stages  of  the  same 

1  Parker  Syms,  in  Medical  Record,  April  2,  189S. 


800      DISEASES  .LVD   INJURIES    OF   THE   ABDOMEN. 

disease.  Tubercular  infection  may  exist  for  some  time  without 
causing  symptoms,  and  acute  symptoms  may  suddenly  arise 
or  intestinal  obstruction  may  occur  from  paresis  of  the 
intestine  or  catching  of  the  gut  under  a  band  or  adhesion. 

Symptoms  of  Oironic  Form. — Usually  the  disease  begins 
insidiously.  The  digestion  is  found  to  be  disturbed,  the 
bowels  are  out  of  order,  the  abdomen  is  distended  and 
tender,  there  is  occasional  colicky  pain,  and  the  patient  loses 
flesh  rapidly. 

In  many  cases  there  is  ascites,  but  the  amount  of  fluid  is 
rarely  very  great.  In  some  cases  the  fluid  is  bloody.  There 
is  usually  moderate  fever,  but  there  may  be  episodes  of  high 
fever  and  protracted  periods  of  subnormal  temperature,  or  the 
temperature  may  be  shghtly  elevated  in  the  evening  and  sub- 
normal in  the  morning.  When  the  temperature  becomes 
markedly  elevated,  pain,  tenderness,  and  distention  notably 
increase.  In  some  cases  there  is  a  continued  fever  resem- 
bling typhoid.  Tumor-like  formations  may  be  detected. 
These  formations  may  consist  of  indurated  omentum,  en- 
cysted exudate,  or  enlarged  mesenteric  glands. 

In  every  suspected  case  a  bimanual  examination  should  be 
made  under  ether,  in  order  to  discover  if  there  are  any 
matted  masses  of  intestine  (Thomson). 

In  many  cases  a  careful  examination  will  detect  tubercular 
disease  of  other  regions  of  the  body,  particularly  of  the  lungs. 
In  some  rare  cases  tubercular  peritonitis  undergoes  sponta- 
neous cure.  In  the  vast  majority  of  instances  death  ensues 
from  the  tubercular  peritonitis  directly  or  from  associated  or 
secondary  disease  in  other  organs. 

If  an  intraperitoneal  tubercular  area  caseates,  a  large  cold 
abscess  may  form,  and  such  an  abscess  may  break  into  the 
intestine  or  may  be  opened  externally,  and  may  be  responsible 
for  the  formation  of  a  fecal  fistula. 

In  a  case  of  tubercular  peritonitis  intestinal  obstruction 
may  occur,  the  gut  getting  caught  by  bands  or  adhesions,  or 
becoming  a  rigid  tube  because  of  the  formation  of  tubercles. 

Treatment. — In  some  cases  medical  treatment  is  of  great 
service.  The  patient  should  be  placed  under  proper  hygienic 
conditions,  nutritious  food  and  tonics  should  be  administered, 
the  abdomen  should  be  counter-irritated  and  massaged,  and 
purgatives  should  be  given  frequently.  Guaiacol  applied  daily 
to  the  abdomen  is  often  of  service.  A  mixture  is  made  of 
I  part  of  guaiacol  and  5  parts  of  olive  oil ;  sj  of  this  mixture 
is  rubbed  into  the  abdomen,  and  the  part  is  covered  with  a 
piece  of  flannel  held  in  place  by  means  of  a  binder.     If  medi- 


t  SUBPHREXIC  ABSCESS.  8oi 

cal  treatment  is  not  soon  productive  of  benefit,  an  operation 
should  be  performed.  It  is  a  curious  fact,  but  one  confirmed 
by  ample  evidence,  that  simple  abdominal  section,  Avithout 
the  introduction  of  germicides  and  without  drainage,  will 
cure  at  least  50  per  cent,  of  the  cases.  The  reason  why 
operation  cures  is  not  known.  It  has  been  thought  that  the 
ascitic  fluid  is  a  culture-medium  for  bacilli,  and  when  it  is 
withdrawn  the  bacilli  die,  but  opposed  to  this  view  is  the  fact 
that  aspiration  is  rarely  curatixe.  It  has  been  suggested  that 
the  operation  brings  numerous  phagocytes  to  the  peritoneum  ; 
that  it  stimulates  vital  resistance ;  that  it  leads  to  the  exu- 
dation of  antitoxic  serum.  The  entrance  of  air  seems  to 
play  a  definite  and  important  part  in  effecting  a  cure. 

The  ascitic  cases  are  most  frequently  benefited  by  oper- 
ation, and  in  these  cases  drainage  is  unnecessary'.  In  encysted 
fluid  operation  usually  cures. 

In  cases  in  which  there  are  numerous  adhesions  the  oper- 
ation is  not  so  likely  to  cure.  Great  care  should  be  exercised 
in  separating  adhesions,  because  the  bowel  is  apt  to  be  torn 
and  a  fecal  fistula  may  result.  It  may  be  necessary  to  sepa- 
rate adhesions  to  relieve  obstruction.  If  operation  is  per- 
formed for  cold  abscess,  tube-drainage  must  be  used  for  some 
days.  Operation  should  not  be  performed  except  to  relieve 
obstruction  or  drain  an  abscess  in  a  very  advanced  case,  in 
a  case  with  notably  high  temperature,  or  in  a  case  with 
marked  and  ad\-ancing  tuberculosis  in  another  region. 

Subphrenic  Abscess. — A  subphrenic  abscess  is  a  col- 
lection of  pus  beneath  the  diaphragm.  The  pus,  as  a  rule, 
occupies  a  part  of  the  lesser  peritoneal  cavity ;  in  rare  in- 
stances it  is  extraperitoneal  (when  it  is  of  renal  origin) ;  in 
some  cases  it  is  contained  in  the  area  between  the  diaphragm, 
cardiac  end  of  the  stomach,  and  liver  or  spleen.  It  is  an 
unusual  thing  for  such  an  abscess  to  break  into  the  general 
cavity  of  the  peritoneum,  but  it  may  break  into  the  pleural 
sac  (MaA'dl). 

Causes. — Perforation  of  a  gastric  ulcer,  perforation  of  the 
gall-bladder  or  gall-ducts,  ulceration  of  the  duodenum,  dis- 
ease of  the  liver,  spleen,  pancreas,  intestine,  appendix,  or 
kidney,  hydatid  disease,  internal  injury,  metastasis,  external 
injury,  caries  of  rib.  or  disease  of  the  pleura  may  be  respon- 
sible for  a  subphrenic  abscess  (]Ma\-dl). 

Symptoms. — There  are  the  constitutional  s\-mptoms  of 
suppuration  and  a  swelling  in  the  subdiaphragmatic  region, 
these  symptoms  ensuing  upon  one  of  the  causative  conditions 
before  mentioned.     In   many  cases  the  abscess-cavity  con- 

51 


802      DISEASES  AND  INJURIES   OF  THE  ABDOMEN. 

tains  gas  as  well  as  fluid.  Empyema  and  subphrenic  abscess 
resemble  each  other.  In  empyema  the  upper  limit  of  the 
fluid  is  concave ;  in  subphrenic  abscess  it  is  convex.  In 
empyema  the  flow  of  pus  through  an  aspirating-needle  will 
be  most  marked  during  inspiration  ;  in  abscess,  during  expira- 
tion— the  same  is  true  of  the  rush  of  gas.  In  empyema  the 
needle  does  not  oscillate ;  in  abscess  it  does.^  The  fact  that 
an  abscess  contains  gas  is  shown  by  the  existence  of  a 
tympanitic  percussion-note  over  a  part  of  the  cavity  and  an 
alteration  in  the  area  of  tympany  with  an  alteration  in  the 
position  of  the  patient.  An  abscess  of  the  liver  does  not  con- 
tain gas  and  alters  decidedly  the  outlines  of  the  organ. 

Treatment. — Incision  and  drainage.  The  incision  in  some 
cases  may  be  made  through  the  abdominal  wall  (epigastric 
region,  iliac  region,  hypochondrium,  or  loin).  In  other  cases 
the  chest-wall  is  incised,  a  rib  is  resected,  the  pleura  is  opened, 
and  the  diaphragm  is  incised. 

The  Liver  and  Gall-bladder. 

Rupture  and  Wounds  of  the  I^iver. — Rupture  of  the 
liver  is  due  to  very  great  force,  and  is  usually  accompanied 
by  injury  of  other  viscera.  It  is  a  very  fatal  accident,  but  an 
attempt  should  be  made  to  save  the  patient  by  opening  the 
abdomen  and  arresting  hemorrhage.  A  wound  of  the  liver 
causes  violent  hemorrhage  which  is  usually  rapidly  fatal. 
Such  a  wound  is  apt  to  divide  bfle-ducts  and  allow  of  the 
escape  of  bile  into  the  peritoneal  cavity.  Bile  if  sterile  will 
do  little  harm,  but  if  it  contains  organisms  will  produce  a 
diffuse  peritonitis.  Patients  do  not  always  die  from  a  serious 
traumatism  of  the  liver.  Some  recover  because  operation 
has  been  performed.  Some  few  recover  without  operation. 
This  last  fact  is  proved  by  reports  of  autopsies  in  which 
scars  were  found  in  the  liver-parenchyma  (Nussbaum).  T.hq 
fatality  which  usually  ensues  on  a  liver  injury  may  be  due  to 
hemorrhage  or  peritonitis.  If  a  surgeon  is  called  to  a 
patient  suffering  from  wound  of  the  liver,  he  must  open  the 
abdomen  to  arrest  hemorrhage.  In  a  penetrating  wound, 
the  wound  in  the  abdominal  wall  must  be  enlarged  in  order 
to  determine  that  the  liver  is  wounded.  If  the  left  lobe  of 
the  liver  is  wounded,  or  if  it  is  uncertain  which  lobe  is 
wounded,  the  incision  should  be  median.  If  the  right 
lobe  is  wounded,  make  a  curved  incision  along  the  line  of 
the    costal    cartilages.     In    some    cases   these  two  incisions 

^  Wharton  and  Curtis,  Practice  of  Surgery. 


HYDATID    CYSTS   OF   THE   LIVER.  803 

are  joined.'  The  convex  surface  of  the  Hver  can  be  reached 
hx  Lannclongue's  plan.  Lannelongue  resects  the  eighth, 
ninth,  tenth,  and  eleventh  costal  cartilages  and  draws  the 
ends  of  the  Tibs  well  out.  When  the  wound  in  the  liver  is 
discovered,  and  well  exposed  deep  sutures  of  catgut  should 
be  inserted  in  the  liver  and  the  capsule  should  be  stitched 
with  fine  silk  (Schlatter).  If  sutures  fail  to  arrest  hemor- 
rhage, the  liver  should  be  sutured  to  the  belly-wall  and  the 
wound  in  the  liver  packed  with  iodoform  gauze.  It  is  use- 
less^'to  tr>^  packing  without  first  attaching  the  liver  to  the 
abdominal  wall,  because  pressure  will  simply  push  the  liver 
away  and  will  not  stop  the  bleeding.  The  cautery  is  a  very 
useful  means  of  arresting  bleeding.  It  should  be  avoided 
if  possible  in  a  large  wound,  because,  even  if  it  arrests  pri- 
mar}^  hemorrhage,  secondaiy  hemorrhage  may  occur.  Alter 
arresting  hemorrhage  wash  out  the  abdomen  with  hot  saline 
fluid,  insert  drainage,  and  close  the  abdominal  wound.  In  a 
case  of  the  author's  in  the  Philadelphia  Hospital  the  liver 
was  wounded  by  the  sharp  ends  of  fractured  ribs.  The 
abdomen  was  opened,  a  w^ound  was  found,  and  bleeding  was 
arrested  by  suturing  the  liver  to  the  belly-wall  and  packing 
the  wound.  The  patient  died,  and  necropsy  showed  another 
wound  on  the  posterior  portion  of  the  organ. 

Hydatid  cysts  of  the  liver  may  be  of  small  size  and  pro- 
ductive of  no  signs  or  symptoms  ;  or  may  be  of  large  size 
and  productive  of  the  signs  of  tumor.  In  the  epigastrium 
the  mass  may  be  prominent  and  may  fluctuate.  In  cyst  of 
the  right  lobe  the  dulness  is  found  in  the  axillar}'  line  and  the 
growth  encroaches  on  the  pleura.  In  a  large  cyst  fluctu- 
ation and  hydatid  fremitus  may  exist.  Hydatid  fremitus  is  a 
vibration  im'parted  to  the  palpating  fingers  of  one  hand  when 
the  fingers  of  the  other  hand  knock  upon  the  cyst.  There 
may  be  no  discomfort  produced  by  even  a  large  cyst,  but,  as 
a  rule,  the  patient  suffers  from  a  dragging  sensation  in  the 
epigastrium  and  pressure-symptoms.  Suppuration  in  the 
cyst  produces,  the  symptoms  of  abscess  of  the  liver  and 
septicemia.  Rupture  of  the  cyst  produces  shock,  and  even 
death.  Rupture  may  take  place  into  the  pleural  sac,  the 
lung,  or  the  peritoneal  cavity.  If  the  shock  is  recovered  from, 
inflammation  arises,  the  area  of  which  depends  upon  the 
structures  damaged.  The  escape  of  even  a  small  quantity 
of  hydatid  fluid  into  the  peritoneal  cavity  produces  urticaria 
(hydatid  toxemia).  Aspiration  for  diagnostic  purposes  is  not 
advisable. 

1  See  Schlatter,  Beitrdge  zur  klmischen  Chirurgie,  Bd.  xv.,  Heft  ii.,  1S96. 


804      DISEASES  AND   INJURIES   OF   THE  ABDOMEN. 

Treatment. — Exploratoiy  incision  may  be  necessary  to 
confirm  the  diagnosis,  and  the  operation  is  completed  at  this 
time.  After  exposing  the  cyst  it  is  packed  around  with  gauze 
and  a  trocar  is  introduced.  When  the  fluid  is  evacuated  the 
sac  is  incised  and  is  drawn  partly  through  the  wound  in  the 
abdominal  wall,  and  is  attached  to  the  wound-margins  (mar- 
supialization). The  endocyst  can  be  removed  by  the  hand 
or  by  irrigation.  A  large  drainage-tube  is  introduced.  If 
there  is  a  considerable  thickness  of  liver-tissue  over  the  cyst, 
incise  the  liver  with  the  cauter}'--knife. 

Abscess  of  the  liver  is  due  to  micro-organisms,  espe- 
cially staphylococci  and  streptococci.  These  organisms  reach 
the  liver  by  the  general  circulation,  or,  what  is  more  frequent, 
are  taken  up  from  the  intestinal  tract  and  reach  the  liver  by 
the  portal  circulation.  The  fact  that  abscess  of  the  hver  is  in 
hot  countries  frequently  preceded  by  amebic  dysentery  has 
lead  to  the  presumption  that  amceba  coli  produces  the  abscess. 
This  is  not  the  case,  and  as  a  matter  of  fact  the  dysentery  is 
due  to  bacteria  (Zancarol).  Habitual  intemperance  and  -con- 
stant overeating  predispose  to  abscess  of  the  liver.  The 
disease  may  follow  traumatism,  dysentery,  diarrhea,  cholan- 
gitis, suppuration  of  a  hydatid  cyst,  gall-stones,  typhoid 
fever,  appendicitis,  and  a  chill  to  the  surface  of  the  body.^ 
Abscess  of  the  liver  may  be  metastatic,  and  such___abscesses 
are  m.ultiple.  It  may  be  caused  by  foreign  bodies  and 
parasites  (Osier).  A  tropical  abscess  is  an  abscess  of  the 
liver  in  an  inhabitant  of  a  hot  country.  It  is  usually 
single,  is  frequently  preceded  by  dysentery,  and  lasts  from 
four  weeks  to  several  years. 

Symptoms. — Osier  tells  us  that  the  solitary  abscess  in 
rare  instances  produces  no-^ymptoms -for. a. considerable  time, 
death  usually  ensuing  from  rupture.  As  a  rule,  the  liver  is 
distinctly  enlarged,  tender,  and  pafriful.  The  pain  usually 
persists,  and  is  not  strictly  localized,  but  radiates  to  the  right 
shoulder  and  back.  An  abscess  at  the  surface  causes  more 
pain  than  an  abscess  deep  Avithin  the  organ.  If  the  abscess 
is  on  the  superior  surface  of  the  liver,  respiration  causes  pain, 
and  in  some  cases  a  friction-sound  can  be  detected  by 
auscultation.  Pain  is  increased  by  pressure,  coughing,  and 
sudden  or  violent  movement.  The  entire  liver  is  enlarged. 
In  some  cases  a  hard  and  smooth  area  can  be  detected. 
Fluctuation  can  rarely  be  obtained.  Jaundice  does  not  occur 
unless  the  common  duct  is  compressed  or  cholangitis  also 
exists.     The  patient  loses   flesh ;   there  is   usually  a  septic 

^  G.  B.  Johnston,  Annals  of  Surgery,  October,  1897. 


IIEFATOPTOSIS,    OR   MOVABLE   LIVER.  805 

fever,  with  an  evening  rise  and  a  morning  remission,  and  a 
severe  sweat  as  the  temperature  falls.  In  a  very  chronic 
caselhere  may  be  no  pyrexia.  As  a  rule,  the  temperature 
resembles  that  of  malaria  and  chills  may  occur.  Sometimes 
it  is  like  that  of  typhoid,  with  the  exception  that  from  time  to 
time  there  are  brief  episodes  of  subnormal  temperature.  The 
appetite  fails  completely,  the  skin  is  of  a  pasty  or  dirty  yellow, 
the  patient  lies  upon  the  affected  side,  and  if  the  liver  becomes 
adherent  to  the  abdominal  wall  there  may  be  edema  of  the 
skin.  Cough  suggests  .that  the  abscess  is  on  the  convex  sur- 
face of  the  fiver,  and  such  a  cough  is  aggravated  by  recum- 
bency. In  some  cases  there  is  diarrhea,  in  others  constipa- 
tion. An  abscess  may  lead  to  pyothorax,  may  break  into  the 
lung,  may  rupture  externally,  or  into  the  bowel,  stomach,  or 
pericardial  sac.  In  pyemic  abscess  the  liver  is  enlarged  and 
tender,  there  is  slight  jaundice,  and  the  general  symptoms 
of  pyemia  are  present. 

Treatment.— Make  an  exploratory  incision.  If  the  abscess 
is  adherent  to  the  parietal  peritoneum,  and  is  not  covered  by 
liver-substance,  at  once  proceed  to  operation.  If  it  is  not 
adherent,  or  is  covered  by  a  considerable  layer  of  liver-sub- 
stance, stitch  the  visceral  peritoneum  to  the  parietal  perito- 
neum and  postpone  further  interference  for  forty-eight  hours. 
The  operation  consists  in  evacuating  the  pus  with  a  trocar 
and  cannula,  incising  the  abscess,  stitching  its  edges  to  the 
edges  of  the  abdominal  wound,  irrigating,  and  inserting  a 
drainage-tube.  If  the  abscess  is  covered  by  a  layer  of  hver- 
tissue,  after  locating  it  with  a  cannula  open  into  it  with  a 
cautery-knife  and  arrest  hemorrhage  by  packing.  When  the 
parietal  and  visceral  peritoneum  are  adherent,  packing  will 
arrest  bleeding ;  if  they  are  not  adherent,  packing  will  only 
push  away  the  movable  liver  (John  O'Connor).  If  pyothorax 
exists,  resect  a  rib,  open  the  pleural  sac,  and  reach  the 
abscess  in  the  liver  by  an  incision  through  the  diaphragmatic 
pleura  and  the  diaphragm  (transthoracic  hepatotomy).  _  A 
pyemic  abscess  should  not  be  operated  upon  unless  it  points, 
because  in  pyemia  multiple  abscesses  exist. 

Hepatoptosis,  or  Movable  I^iver.— This  condition 
is  very  rare.  It  is  due  to  relaxation  of  the  supports  of 
the  liver.  It  may  occur  alone,  but  it  is  more  often  a  part  of 
a  general  abdominal  relaxation  or  of  Glenard's  disease,  and 
often  the  kidney  is  movable.  The  liver  may  descend  into 
the  lower  abdomen,  may  be  upside  down  (Demarquay), 
may  rotate  on  its  transverse  axis  (Griffiths),  may  be  movable,  or 
may  be  anchored  by  adhesions.      In  some  cases  the  liver  is 


8o6      DISEASES  AND  INJURIES   OF  THE  ABDOMEN. 

healthy  and  in  some  it  is  diseased.  The  liver  is  supported  by 
ligaments  and  also  by  the  vena  cava  (Faure),  the  abdominal 
wall,  and  the  intestines  (Glenard).  The  cause  of  the  condition 
is  in  dispute.  It  can  result  from  relaxation  of  the  belly-wall, 
relaxation  of  the  ligaments,  enteroptosis,  and  great  enlarge- 
ment of  the  gall-bladder.  It  is  most  common  in  women,  may 
be  produced  by  tight  lacing  or  strains,  or  the  dragging  of 
an  adherent  tumor.  The  condition  is  sometimes  congenital.^ 
Hepatoptosis  is  readily  diagnosticated.  In  most  cases  the 
shape,  the  movability,  and  the  absence  of  the  liver  from  its 
proper  position  are  diagnostic.  Even  when  the  organ  is  dis- 
located and  attached  it  is  missed  from  its  proper  abode. 

Treatment. — By  the  use  of  an  elastic  support.  If  this 
fails  to  give  relief,  open  the  abdomen  and  fasten  the  liver  to 
the  abdominal  wall  (hepatopexy).  Ramsay  rubbed  the  upper 
surface  of  the  liver  with  gauze  to  promote  adhesion,  and 
transfixed  the  round  ligament  with  a  suture,  which  was  also 
carried  around  the  cartilage  of  the  seventh  rib.  Richelott, 
Areilza,  and  Treves  have  operated  for  this  condition. 

Gall-stones. — Gall-stones  are  formed  during  life  in  the 
gall-bladder  or  bile-ducts  by  the  agglutination  of  materials 
which  have  precipitated  from  bile.  The  nucleus  of  a  gall- 
stone may  be  a  mass  of  bacteria,  a  blood-clot,  epithelium, 
cr>'stals  of  cholesterin  or  carbonate  of  lime,  or  a  cast  of  a 
small  duct.^  The  condition  of  the  body  which  leads  to  the 
formation  of  gall-stones  is  designated  by  the  term  chole- 
lithiasis (Brockbank).  But  one  stone  may  be  present  or  great 
numbers  may  exist.  Solitary  stones  may  be  nearly  round  or 
cylindrical.  When  several  stones  or  many  stones  exist  the 
mutual  pressure  often  leads  to  the  formation  of  facets 
(Naunyn).  In  color  calculi  may  be  pale  yellow,  green, 
black,  or  brown.  Some  are  heavier  than  bile  and  some  are 
lighter.  Brockbank  gives  the  following  varieties  of  gall- 
stones :  pure  cholesterin  stones,  stratified  cholesterin  stones, 
common  or  gall-bladder  calculi,  mixed  bilirubin  calcium 
calculi,  pure  bilirubin  calcium  calculi,  and  certain  rare  forms.^ 
Gall-stones  usually  take  origin  in  the  gall-bladder,  but  may 
arise  in  the  common  duct,  the  cystic  duct,  the  hepatic  duct, 
or  the  smaller  ducts  of  the  liver.  As  a  rule,  however,  calculi 
in  the  common  or  cystic  duct  were  not  formed  there,  but 
were  transported  from  the  gall-bladder  or  hepatic  ducts. 

^  See  Terrier  and  Auvray,  in  Rev.  de  Chir.,  August  and  Sept.,  1S97,  an  article 
I  have  freely  used. 

-  Bevan,  in  Chicago  Med.  Recorder,  April,  1898. 
'  Brockbank's  treatise  on  Gall-stones. 


GALL-STOXES.  SO/ 

Causes. — The  cause  is  a  catarrhal_condition  of  the  bile- 
ducts,  due  particularly  to  Tlie  entrance  of  bacteria^  from  the 
intestine  (colon  bacilli,  typhoid  bacilli,  pus  organisms,  pneu- 
mococci).     This  catarrhal  condition  causes  stagnation  of  bile. 

The  chief  predisposing  causes  are  advancing  years,  insuf- 
ficient exercise,  the  consumption  of  an  excess  of  nitrogenous 
food,  gouty  tendencies,  conditions  which  interfere  with  the 
emptying  of  the  gall-bladder,  cardiac  disease,  and  cancer  of 
the  liver.  The  disease  is  more  common  in  the  insane  than 
in  the  mentally  sound,  and  in  women  than  in  men.  The 
special  liabilit}-  of  women  may  be  brought  about  b}-  tight 
lacing,  pregnancy,  inactivit\%  or  movable  right  kidney.  There 
are  two  forms  of  the  condition  to  be  considered.  The  acute 
type,  due  to  efforts  made  by  the  gall-bladder  or  duct  to  expel 
the  concretion  ;  and  the  chronic  condition,  in  which  a  cal- 
culus is  lodged  for  a  long  time,  or  in  which,  as  soon  as  one 
calculus  is  passed  into  the  intestine,  "  another  begins  its 
journey"  (Brockbank).  The  fact  that  bacteria  cause  the 
condition  must  not  lead  us  to  infer  that  pus  is  formed.  The 
bacteria  are  present  in  small  numbers  or  else  their  virulence 
is  greatly  mitigated,  they  produce  only  catarrhal  inflamma- 
tion, quantities  of  cholesterin  are  secreted,  the  bile  stagnates, 
and  a  stone  forms.  In  many  cases  the  stone  or  stones  never 
cause  trouble.  xA.  very  small  stone  usually  passes  freely, 
A  larger  stone  in  passing  causes  coHc.  A  still  larger  stone 
remains  in  the  gall-bladder,  or  becomes  fixed  in  the  cystic 
duct  or  the  intestinal  outlet  of  the  common  duct. 

Symptoms. — The  formation  of  a  stone  requires  several 
months,  and  during  the  antecedent  period  of  gastro-intes- 
tinal  catarrh,  "the  prodromal  state"  of  Kraus,  certain  symp- 
toms usually  exist,  \'\z. :  constipation,  flatulence,  loss  of  appe- 
tite, migraine,  uneasy  sensations  in  the  epigastrium  or  right 
hypochondrium.  sallowness  of  the  skin,  slight  yellowness  of 
the  conjunctiva,  scantiness  of  urine,  which  excretion  is  satu- 
rated with  uric  acid,  and  may  after  a  time  contain  a  little  bile. 
If  this  condition  is  not  arrested  by  treatment,  it  grows  worse. 
The  abdomen  becomes  decidedly  distended  ;  pressure  over 
the  stomach  or  liver  may  cause  distinct  uneasiness,  or  even 
pain  ;  acid  indigestion  is  veiy  troublesome,  violent  attacks 
of  migraine  occur,  constipation  becomes  more  decided,  the 
feces  become  clay-colored,  gastralgia  may  occur,  the  skin  is 
apt  to  be  slightly  jaundiced,  itching  is  complained  of,  the 
patient  is  irritable  and  sleeps  poorly.  The  liver  is  found  to 
be  enlarged,  and  the  urine  contains  distinct  amounts  of  bile. 
When    the    patient  reaches    this  stage   gall-stones  are  very 


8o8      DISEASES  AND   INJURIES   OF   THE  ABDOMEN 

liable  to  form.  These  symptoms  may  pass  away  even  if  a 
concretion  forms.  It  is  quite  true  that  in  some  cases  a  stone 
exists  for  years  without  causing  trouble ;  but,  as  a  rule,  it 
o-reatly  aggravates  the  condition.  When  a  stone  forms 
pain  is  apt  to  become  a  marked  feature  of  the  case.  A 
sense  of  pressure  or  of  soreness  in  the  hepatic  region  has 
added  to  it  sudden  and  transient  paroxysms  of  pain,  due 
to  the  passage  of  thick  bile  from  the  gall-bladder  and  small 
ducts,  or  of  gravel  from  the  small  ducts  urged  on  by  bile- 
pressure.  When  a  stone  begins  to  pass  from  the  gall-blad- 
der violent  colic  is  experienced.  Such  a  colic  usually 
comes  on  very  suddenly,  and  often  about  three  hours  after  a 
meal.  It  may,  however,  come  on  gradually,  the  patient 
complaining  greatly  of  flatulence.  The  pains  are  violent, 
spasmodic,  and  paroxysmal,  and  over  the  hepatic  and 
epigastric  regions,  "  radiating  upward  over  the  right  half  of 
the  thorax  "  (Kraus).  The  patient  is  profoundly  nauseated, 
and  usually  vomits,  the  abdomen  is  distended,  and  a  con- 
dition almost  of  collapse  is  soon  reached.  The  attack  lasts 
a  variable  time,  and  terminates  by  the  stone  passing  into  the 
intestine  or  falling  back  into  the  bladder.  After  its  conclu- 
sion, if  the  feces  are  examined  carefully  during  several  days, 
the  stone  may  be  discovered.  The  fact  that  no  stone  is  dis- 
covered does  not  prove  that  no  stone  was  passed,  because  a 
cholesterin  stone  will  be  destroyed  in  the  intestinal  canal. 
Jaundice  almost  invariably  follows  the  attack  in  about  twenty- 
four  hours  and  lasts  several  days.  If  the  stone  is  impacted, 
after  a  time  the  pains  become  less  violent,  but  again  and 
again  the  patient  suffers  from  aggravation  of  them.  An 
individual  may  get  about  with  impacted  stone,  but  again  and 
again  fierce  attacks  of  colic  occur,  and  if  the  stone  is  in  the 
common  duct  the  patient  becomies  and  remains  deeply  jaun- 
diced.    In  certain  cases   attacks  of  gall-stones   are   accom- 

^.[}    panied  by  febrile  seizures  resembling  malaria. 

••'.,'■  If  a  stone  lodges  in  the  cystic  duct,  it  does  not  cause  jaun- 
dice. It  grows  in  size  from  incrustation,  prevents  the  entrance 
of  bile  into  the  gall-bladder,  and  the  bladder  becomes  filled 
with  mucus  (hydrops  of  the  gall-bladder).  If  a  bladder  so 
blocked  becomes  infected,  pus  forms,  and  the  condition  known 
as  empyema  of  the  gall-bladder  exists.  An  empyema  of 
the  gall-bladder  may  rupture  into  the  bowel,  the  peritoneal 
cavity,  or  even  through  the  skin. 

If  a  stone  blocks  the  common  duct,  jaundice  always  exists. 
Blocking  may  be  complete,  and  the  stone  may  ulcerate  into 
the  bowel  or  the  peritoneal  cavity.     Blocking  may  be  incom- 


GALL-STONES.  809 

plcte,  the  stone  acting  as  a  ball-valve  and  producing  intermit- 
tent colic  and  jaundice  (Christian  Fenger).  Fenger  points 
out  that  if  a  stone  remains  fixed  in  the  common  duct  the 
liver  becomes  tender  and  enlarged ;  but  if  a  stone  floats  about 
in  the  common  duct,  the  gall-bladder  undergoes  atrophy.  In 
complete  obstruction  the  stools  become  clay-colored  and 
bilirubin  is  found  in  the  urine. 

Gall-stones  may  lead  to  suppurative  inflammation  of  the 
gall-bladder  or  bile-passages,  ulceration,  occlusion  of  the 
neck  of  the  gall-bladder,  dilatation  of  the  stomach  from  the 
formation  of  adhesions  which  kink  the  pylorus,  abscess, 
peritonitis,  empyema  of  the  gall-bladder,  and  cancer  of  the 
gall-bladder.  If  the  patient  develops  distinct  infection  of  the 
gall-bladder  or  bile-ducts,  he  will  suffer  from  chills,  fever, 
and  sweats. 

Gall-stones  may  lead  to  cancer  of  the  gall-bladder,  and 
cirrhosis  of  the  liver.  A  stone  may  ulcerate  into  the  bowel 
and  cause  intestinal  obstruction.  It  may  be  difficult  to  make 
a  diagnosis  between  gall-stones  with  icterus  and  cirrhosis  of 
the  liver  with  icterus.  In  the  former  case  the  urine  contains 
bilirubin  and  in  the  latter  case  urobilin. 

Treatment. — In  the  prodromal  stage  and  after  recovery 
from  an  attack  insist  on  the  patient  taking  considerable  out- 
door exercise.  Direct  him  to  take  a  cold  sponge-bath  every 
morning,  to  move  the  bowels  freely  every  day,  and  to  em- 
ploy a  simple  diet.  The  patient  should  avoid  all  highly 
seasoned  foods,  pastry,  rich  soups,  fatty  food,  cheese,  alco- 
hol, and  sweets.     Alkalies  internally  are  of  value. 

During  the  attack  give  an  enema,  apply  hot  turpentine 
stupes  over  the  hepatic  region,  and  give  a  hypodermatic  injec- 
tion of  morphin  and  atropin.  If  vomiting  does  not  occur, 
let  the  patient  drink  a  large  amount  of  warm  water  to  favor 
it.     After  the  attack  administer  a  purgative. 

When  the  attack  has  terminated  examine  carefully  for  any 
evidence  of  inflammatory  trouble  in  the  hepatic  region. 

In  certain  cases  operation  becomes  necessary.  Mayo 
Robson  advises  operation  in  the  following  cases :  ^  in  fre- 
quently recurring  biliary  colic  without  jaundice,  whether  the 
gall-bladder  is  enlarged  or  not ;  in  cases  of  enlargement  of 
the  gall-bladder  without  jaundice,  even  if  there  is  no  pain  ; 
in  persistent  jaundice  which  was  ushered  in  by  pain,  painful 
seizures  occurring,  whether  or  not  febrile  attacks  occur;  in 
empyema  of  the  gall-bladder ;  in  peritonitis  beginning  in  the 
gall-bladder  region ;  in  intrahepatic  abscess  and  in  abscess 

1  Mayo  Robson  on  the  Gall-bladder  and  Bile-ducts. 


8lO      DISEASES  AND   INJURIES   OF  THE  ABDOMEN. 

about  the  liver,  gall-bladder,  or  bile-ducts ;  in  some  cases 
where  the  stones  have  been  passed,  but  adhesions  remain  and 
produce  pain  ;  in  fistula  cases  ;  in  some  cases  of  persistent 
jaundice  due  to  obstruction  of  the  common  duct,  although 
there  may  be  a  possibility  of  cancer  existing ;  in  phlegmo- 
nous cholecystitis  and  gangrene  of  the  gall-bladder.  Besides 
these  conditions  which  may  be  produced  by  gall-stones, 
Robson  operates  for  wounds  of  the  gall-bladder,  rupture  of 
the  gall-bladder,  infective  and  suppurative  cholangitis,  and 
for  some  conditions  of  chronic  catarrh  of  the  bile-ducts  and 
gall-bladder/ 

The  common  operation  is  cholecystotomy,  which  consists 
in  opening  the  gall-bladder,  removing  the  stones,  and  making 
a  fistula  of  the  gall-bladder  (page  853).  The  fistula  is  per- 
mitted to  heal,  hence  we  say  cholecystotomy  rather  than 
cholecystostomy.  The  operation  of  incision,  removal  of  the 
stone,  and  suture  of  the  gall-bladder  is  known  as  chole- 
cystendysis.  If  calculi  exist  in  the  common  duct,  it  may  be 
possible,  after  celiotomy,  to  manipulate  them  back  into  the 
bladder.  In  some  cases  cholecystotomy  is  performed,  or  a 
fistula  is  made,  and  the  duct  and  bladder  are  frequently  irri- 
gated. In  other  cases  the  stone  may  be  crushed  by  the 
fingers  manipulating  the  duct  and  the  concretion  within  it 
(choledocholithotrity).  The  duct  may  be  opened,  and  after 
the  removal  of  the  stone  closed  by  sutures  (choledochotomy). 
If  the  stone  is  impacted  near  the  outlet  of  the  duct,  the 
duodenum  is  incised  and  the  stone  removed  (choledocho- 
duodenotomy).  A  dilated  bile-duct  may  be  anastomosed  to 
the  bowel  (choledocho-enterostomy)  or  to  the  surface  (chole- 
dochostomy).  The  obstruction  may  be  side-tracked  by 
anastomosing  the  gall-bladder  to  the  bowel  (cholecystenter- 
ostomy)  (p.  854),  or  a  dilated  duct  to  the  bowel  (chole- 
docho-enterostomy). In  some  cases  the  gall-bladder  is  re- 
moved (cholecystectomy).  Cysticotomy  is  incision  of  the 
cystic  duct. 

The  Pancreas. 

Hemorrhage. — Multiple  minute  hemorrhages  into  the 
pancreas  produce  no  definite  symptoms,  and  may  occur  in 
purpura  and  in  scurvy.  Fatal  pancreatic  hemorrhage  may 
be  the  "terminal  condition  or  event"  in  acute  pancreatitis  or 
in  cancer  of  the  pancreas.^     Anders  points  out  that  not  only 

^  Robson's  treatise,  from  which  the  above  is  taken,  is  a  valuable  exposition 
of  the  surgery  of  the  gall-bladder  and  bile-ducts. 

*  J.  M.  Anders,  paper  read  before  Amer.  Med.  Assoc,  in  1899. 


CYSTS    OF   THE   PANCREAS.  8ll 

may  pancreatic  hemorrhage  result  from,  but  it  may  be  fol- 
Swed  by  acute  pancreatitis.  It  may  arise  when  there  is  fat- 
necrosis  or  after  traumatism.  Pancreatic  hemorrhage  is  a 
reco^nfzed  cause  of  sudden  death.  The  symptoms  may 
an^e^vithout  warning.  They  compnse  severe  pamnau  a 
vomitino-  abdominal  tenderness,  distention  great  restless 
nes  constipation,  and  collapse.  The  blood  may  collect  in 
he  lesser  peritoneal  cavity,  or  about  the  spleen  and  left 
kidney  (Prince  and  F.  W.  Draper).  It  may  be  possible 
h,  some  cases  to  arrest  the  hemorrhage  by  operative  pro- 

""' Acute  PancreatitiS.-Hemorrhagic  pancreatitis  is  an 
inflammation  of  the  fibrous  and  fatty  interstitial  tissue  (Fitz), 
and  occurs  in  people  m  middle  life,  and  especially  in  tipplers. 
?  begins  suddenly:  there  are  violent  pam,  nausea  and  vomi  - 
inc;  moderate  fever,  constipation,  distention,  and  rapid  col- 
iSeTRe-Sd  Fitz,  and  Osier  and  Welch).  Inflammation 
of^  the  plncreas  with  pus-formation  is,^  as  a  rule,  more 
Ironic. 'The  symptoms  of  both  conditions  a-;imilar  a 
the  be-inning  of  the  attack,  and  if  pus  forms  a  septic  fever 
develops      In  some  cases  the  pancreas  becomes  gangrenous. 

The'real  cause  of  sudden  death  in  acute  pancreatitis  has 
been  much  disputed.  In  one  of  Anders's  cases  the  amount 
o  bloodfost  was  only  eight  ounces,  and  yet  death  occurred^ 
t  has  been  suggested  that  death  is  due  to  pressure  upon  the 

mUunar   ganglia  by  the  enlarged  organ  and  con    quen 
cardiac  paralysis  (Friedreich).     It  seems  likely  that  death  is 

'X::^^^-t'^^^l^^^  of  the  difficulty  of  distinguishing 
acute  pancreatitis  from  intestinal  obstruction  and  perforated 
ulcer  of  the  stomach,  in  any  case  where  either  of  these  con 
dtic^is  is  suspected  an  exploratory  laparotomy  is  mdicated. 
Oskr  speaks 'of  cases  of  hemorrhagic  pancreatitis  m  which 
ooeration  was  followed  by  recover>'. 

CvSts  Of  the  pancreas  are  most  common  between  the 
aees  of  twenty  and  thirty,  and  occasionally  follow  injury. 
They  are  due,  as  a  rule,  to  obstruction  of  the  orifice  of  the 
common  due  or  of  the  pancreatic  duct  by  calculi,  tumor- 
pr^^ure  or  cicatricial  contraction.  These  cysts  may  grow 
rao  dly  or  slowlv.  Thev  usually  produce  considerable  pain 
Tn'd  gastro-intestinal  disturbance,  and  -^Y  ^^  accornpan^ed  by 
chan-es  in  the  feces,  mental  depression,  and  diabetes.  Exam- 
Sn  of  the  abdomen  discovers  a  mass  which  is  usually 
median  is  elastic,  and  is  dull  at  some  parts  but  resonant  at 
^hers  ^^4e  it  is  crossed  by  the  colon).     In  some  cases  the 


8l2      DISEASES  AND   INJURIES   OF   THE  ABDOMEN. 

mass  fluctuates.     The  fluid  of  the  cyst  is  apt  to  contain  urea, 
and  will  convert  starch  into  sugar. 

Treatment. — Tapping  is  contraindicated.  It  might  do 
much  damage.  In  Keen's  case,  if  an  aspirating-needle  had 
been  introduced  it  would  have  perforated  both  walls  of  the 
stomach.  Confirm  the  diagnosis  by  an  exploratory  incision. 
It  m.ay  be  possible  to  extirpate  the  cyst,  but  it  is  better  to 
incise  it,  stitch  its  edges  to  the  belly-wall,  and  drain. 

The  Spleen. 

Wounds  and  Rupture. — A  wound  of  the  spleen  causes 
great  hemorrhage,  and  if  no  surgical  aid  is  offered  will 
rapidly  produce  death.  The  treatment  consists  in  celiotomy 
and  splenectomy. 

Rupture  of  the  spleen  produces  the  signs  and  symptoms 
of  intra-abdominal  hemorrhage.  The  blood  clots  so  rapidly 
that  it  gathers  in  the  left  loin,  and  is  not  commonly  diffused 
throughout  the  abdomen.  Certain  recognition  of  the  condi- 
tion may  require  exploratory  celiotomy.  If  such  a  con- 
dition is  suspected  while  intravenous  saline  transfusion  is 
being  employed,  the  surgeon  opens  the  abdomen,  and  if 
the  spleen  is  ruptured,  removes  it. 

Abscess  of  the  spleen  is  a  rare  condition  which  is 
metastatic  in  origin.  Pain  is  felt,  and  enlargement  is  noted 
in  the  splenic  region,  and  the  symptoms  of  pyemia  exist. 
The  treatment  consists  in  incision  and  drainage. 

Wandering"  Spleen. — The  spleen  may  wander  into  any 
part  of  the  general  peritoneal  cavity.  This  condition  is 
seldom  met  with  except  in  women.  It  is  most  common  in 
women  who  have  borne  children  (J.  Bland  Sutton).  A 
wandering  spleen  may  undergo  atrophy,  engorgement,  or 
axial  rotation  (J.  Bland  Sutton).  The  organ,  when  dis- 
placed, drags  upon  the  stomach,  producing  dilated  stomach  ; 
it  may  interfere  with  the  bile-duct,  causing  jaundice ;  it  may 
cause  intestinal  obstruction  by  forming  adhesions,  or  may 
cause  uterine  retroflexion  or  prolapse  by  passing  into  the 
pelvis. 

J.  Bland  Sutton  says  this  condition  may  endanger  life,  as 
it  may  lead  to  rupture  of  the  stomach,  intestinal  obstruction, 
splenic  abscess,  or  splenic  rupture.^  A  wandering  spleen  can 
be  identified  by  the  fact  that  it  has  a  notch  upon  its  edge, 
and  can  be  pushed  about  the  abdomen.  When  this  con- 
dition exists  the    spleen    may  be    missed    from    its    normal 

^  British  Aledical  Jou7-nal,  Jan.  i6,  1897. 


ABDOMIXAL    SECTIOX.  813 

situation.     Always    examine    the    blood    in   order  to  deter- 
mine if  leukemia  or  malaria  exists. 

Treatment. — Greiftenhagen  advocates  suturing  the  organ 
in  place  (splenopexy).  Most  surgeons  prefer  to  perform 
splenectomy.  In  a  case  without  leukemia  the  operation  is 
ver\'  successful.  Splenectomy  in  wandering  spleen  is 
rarely  followed  by  serious  blood-changes  or  other  trouble. 
The  reason  is  that  a  wandering  spleen  is  usually  a  diseased 
organ,  ha\-ing  undergone  hypertrophy  or  fibroid  change,  and 
other  structures  have  taken  on  splenic  function.  Splenec- 
tomy should  not  be  undertaken  if  leukemia  exists.  In  such 
a  case  apply  a  support  and  employ  medical  treatment  for  the 
existing  disease. 


Operations  upon  the  Abdomen. 

Abdominal  Section  (^Celiotomy ;  Laparotomy^ — Before 
opening  the  abdominal  cavity  for  exploratory'  purposes  or 
to  gain  access  to  some  area  of  abdominal  or  pelvic  disease, 
the  patient  is  carefully  prepared  as  for  any  other  operation. 
In  an  appendicitis  case  the  patient  is  moved  with  the  utmost 
care  and  is  prepared  for  operation  most  gently,  because  of 
the  possible  danger  of  rupturing  an  abscess.  In  an  emer- 
gency case  no  prolonged  or  complicated  method  of  cleansing 
can  be  employed.  The  abdomen  and  loins  are  scrubbed 
carefully  with  soap  and  water,  special  attention  being  given  to 
the  umbilicus,  thepubes  are  shaved,  the  soapsuds  are  washed 
away  with  sterile  water,  the  surface  is  gently  scrubbed  w'ith 
alcohol  and  then  with  a  hot  solution  of  corrosive  sublimate 
(i  :  1000),  and  covered  with  gauze  wet  with  the  sublimate 
solution.  Whenever  there  is  time  it  is  eminently  desirable 
to  prepare  the  patient  the  day  before.  The  instruments 
required  depend  upon  the  nature  of  the  case.  As  a  rule, 
there  are  required  scalpels,  scissors,  a  dry  dissector,  two 
pairs  of  dissecting-forceps,  hemostatic  forceps,  pedicle-for- 
ceps, Hagedorn  needles,  calyx-eyed  intestinal  needles,  a 
needle-holder,  drainage-tubes,  gauze  pads,  gauze  for  sponging, 
silk,  catgut,  silkworm-gut.  the  Paquelin  cauter}%  an  electric 
light,  also  an  instrument-bag  and  a  saline  solution  for  hypo- 
dermoclysis  or  intravenous  infusion.  Always  count  the  in- 
struments, sponges,  and  pads,  and  w^rite  down  the  number, 
and  count  them  again  after  operation.  This  rule  is  adopted 
so  that  no  instrument,  sponge,  or  pad  will  be  left  in  the  abdo- 
men. The  abdominal  pads  and  sponges  are  not  used  when 
dr}-.    Dn.-  sponges  injure  the  peritoneum  and  favor  the  subse- 


8 14      DISEASES  AND   INJURIES   OE   THE  ABDOMEN. 

quent  development  of  adhesions  (Sanger).  The  pads  and 
sponges  should  be  wrung  out  in  hot  normal  salt  solution  be- 
fore using. 

Operation. — An  anesthetic  is  given.     In  some  cases  the 
patient  is   placed  recumbent,  in  others  is  put  in  the  position 

of  Trendelenburg  (Fig.  270).  The 
patient  is  to  be  carefully  protected 
from  cold,  the  extremities  and  the 
chest  are  covered  with  blankets, 
and  sterilized  sheets  are  placed 
well  around  the  field  of  operation. 
The  parts  are  sterilized  anew  im- 
F^yo.-The  Trendelenburg  mediately  bcforc  Operating.  The 
p°^'"°"-  surgeon  steadies  the  skin  of  the 

belly  with  the  fingers  of  his  left  hand,  and,  holding  the  knife  in 
the  right  hand,  makes  an  incision  about  two  inches  long.  This 
incision  is  often  made  in  the  middle  line  midway  between  the 
pubes  and  umbilicus;  but  may  be  in  the  semilunar  line, in  the 
epigastric  region,  or  in  some  other  situation.  The  first  cut 
goes  to  the  aponeurosis.  Clamp  the  vessels.  Do  not  hunt  for 
the  linea  alba  below  the  umbilicus,  but  go  right  through  or  be- 
tween the  recti  muscles.  Above  the  umbilicus  the  Hnea  alba 
is  very  distinct  and  the  surgeon  often  cuts  through  it.  Divide 
the  transversalis  fascia,  beneath  which  is  a  little  fat,  and  expose 
the  peritoneum.  The  latter  structure  is  recognized  by  its  glis- 
tening appearance,  by  the  ease  with  which  it  can  be  pinched 
up  between  the  finger  and  thumb,  and  by  the  readiness  with 
which  its  opposed  surfaces  may  be  made  to  glide  over  each 
other.  On  identifying  the  peritoneum,  catch  it  at  each  side  of 
the  incision  with  forceps,  raise  a  fold,  nick  it  with  a  knife,  and 
open  it  with  scissors  to  the  length  of  the  external  wound. 
To  prevent  stripping  of  the  peritoneum  a  good  plan  is 
to  anchor  it  to  the  belly-wall  with  a  stitch  on  each  side  of 
the  incision.  Through  the  wound  thus  made  the  abdomen 
and  its  contents  are  explored,  the  trouble  located,  and  deter- 
mination made  as  to  whether  or  not  further  operation  is  advis- 
able, and,  if  it  is  advisable,  what  form  it  shall  take.  It  may 
be  necessary  to  enlarge  the  wound.  This  is  done  by  placing 
the  index  and  middle  fingers  of  the  left  hand  in  the  belly, 
with  their  pulps  against  the  peritoneum,  in  the  line  where 
the  surgeon  will  cut,  to  serve  as  supports  to  the  scissors  and 
as  guards  to  intraperitoneal  structures.  The  scissors  are 
introduced  and  the  wound  is  enlarged  upward,  around  the 
umbilicus  if  necessary.  As  soon  as  the  incision  is  complete 
it  is  a  good  plan  to  push  a  large  pad  into  Douglas's  pouch 


ABDOMINAL    SECTION.  815 

and  leave  it  there  until  the  operation  is  finished,  when  it  must 
be  removed.  Slender  adhesions  are  broken  offAvith  the  finger 
or  are  pushed  off  with  gauze ;  firm  adhesions  are  tied  in  two 
places  and  cut  between  the  ligatures. 

The  toilet  of  the  peritoneum  is  important  after  the  opera- 
tion is  completed.     Following  a  clean  laparotomy,  when  but 
little  blood  has    flowed  into  the  cavit)',  flushing  is   not  re- 
quired ;  if    much  blood   has  flowed   or  if  septic  matter  has 
passed' into  the  peritoneal  cavity,  after  removing  the  sponge 
from    Douglas's    pouch    flush    the    belly    thoroughly    with 
hot  normal  salt   solution,  empty  out  most  of  the  fluid,  but- 
let  a  pint  or  more   remain  in  the  abdomen.     The  retention 
of  saline  fluid  in  the  belly  minimizes  shock.     It  is  absorbed 
with  great  rapidity  after  the  operation  if  the  patient  is  placed 
with  his  head  lower  than  his  feet,  because  in  this  position 
the  saline  fluid  gravitates  to  the  diaphragmatic  region,  where 
absorption  is  ver}^  active.     If  there  is  widespread  infection, 
eviscerate,  wipe    out   the  peritoneum  with    pads    soaked    in 
hot  normal  salt  solution,  and  wipe  the   intestines  carefully, 
slowly    returning    them    as    they    are    wiped.     Extravasated 
septic    matter    is    apt    to  collect    in    the    peritoneal    fossae 
and  between  the  liver  and   diaphragm,  and   these   regions 
must  be  carefully  wiped  or  irrigated.     In  some  cases  it  is 
desirable  to  drain    through  a  lumbar  incision.     Rutherford 
Morrison  has  pointed  out  that  on  the  right  side_  a  lumbar 
opening    into    the    right    kidney    pouch    will    drain  a    fossa 
which    holds    over  a   pint    of  fluid,    and    which,    when  the 
patient  is  recumbent,  is  the  most  dependent  portion  of  the 
peritoneal  cavity.     In  some  cases  a  drainage-opening  is  made 
on  each  side  of  the  belly  or  above  the  pubis,  or  through  the 
vagina.     In   septic   cases   it   may  be  advisable  to  drain  with 
several  pieces  of  iodoform  gauze  instead  of  inserting  tubes. 
Before  closing  the  Avound  arrest  hemorrhage  and  count  the 
instruments  and  sponges.     In  most  instances  drainage  is  not 
needed,  but  it  must  be  used  in  septic  cases  and  when  hemor- 
rhage  has   been   severe.     We  may  drain  by  a  rubber  tube, 
strands  of  gauze,  or  a  glass  tube.     If  a  glass  tube  is  used,  it 
is  introduced  at  the  lower  angle  of  the  wound  and  reaches 
the  bottom  of  the  pouch  of  Douglas.    This  tube  is  repeatedly 
emptied    during   the    progress  of  the    case    by  means  of  a 
syringe.     In   closing  the  wound  some   surgeons    close    the 
peritoneum  with  a  continuous   catgut  suture  and  close  the 
belly-wall   with  interrupted  sutures  of  silkworm-gut;  some 
operators     close    with    interrupted     silkworm-gut    sutures, 
including  peritoneum,  muscles,  and  skin  in  each  stitch.  When 


8l6      DISEASES  AND   INJURIES   OF   THE  ABDOMEN. 

passing  the  sutures  have  a  gauze  pad  under  the  wound  and 
be  very  careful  not  to  include  bowel  or  omentum.  It  is 
necessary  to  tighten  and  tie  most  carefully  to  prevent  omen- 
tum being  caught  in  the  loop  of  the  stitch.  In  badly  infected 
cases  the  wound  is  often  kept  open.  Dress  with  aseptic 
gauze  and  wood-wool,  and  apply  a  flannel  binder. 

Operation  for  Acute  Appendicitis. — Before  operating  try 
to  locate  the  situation  of  the  appendix,  and  the  relation 
the  area  of  infection  bears  to  the  ascending  colon.  The  inci- 
sion should  be  over  the  seat  of  disease.  In  the  rare  left- 
sided  cases  and  in  median  cases  the  incision  is  on  the  left  side 
or  median.  In  some  cases  where  the  appendix  is  posterior 
the  cut  may  be  in  the  loin.  In  one  case,  I  opened  a  puru- 
lent collection  through  the  rectal  wall.  In  the  vast  majority 
of  cases  the  incision  is  made  in  the  right  iliac  region. 

In  acute  appendicitis  when  there  is  not  thought  to  be  a 
distinct  abscess  the  incision  usually  made  is  two  inches 
internal  to  the  anterior  superior  iliac  spine  and  perpendicular 
to  a  line  drawn  from  the  spine  to  the  umbilicus  (Fig.  271). 
The  skin  incision  is  usually  three  inches  in  length,  the  upper 
third  of  the  incision  being  above  the  omphalospinous  line ; 
the  incision  in  the  peritoneum  is  from  two  to  three  inches  in 
length,  but  if  there  are  many  adhesions  it  may  be  necessar}^ 
to  make  it  much  longer.  The  oblique  incision  may  be 
carried  out  as  advised  by  McBurney.  An  oblique  incision 
in  this  situation  cuts  very  few  nerve-fibers,  and  hence  is  not 
followed  by  marked  muscular  wasting,  a  condition  which 
strongly  predisposes  to  hernia.  Further,  as  Van  Hook 
points  out,^  the  oblique  incision  enables  the  surgeon  to  reach 
freely  all  the  ordinary  areas  of  appendix  trouble,  the  wound 
is  parallel  with  the  lines  of  traction  of  the  abdominal  muscles 
and  does  not  tend  to  gap  widely.  After  opening  the  perito- 
neum examine  very  gently  to  detect  the  situation  of  the 
appendix,  and  if  there  are  or  are  not  adhesions.  In  a  very 
recent  case  and  in  a  very  acute  case  there  will  probably  be 
no  adhesions  unless  there  have  been  previous  attacks.  Sur- 
round the  region  of  infection  with  strips  of  iodoform  gauze, 
each  strip  being  two  and  one-half  inches  wide,  fifteen  inches 
long,  and  four  layers  in  thickness.  The  edges  of  the  wound 
should  be  lifted  up  by  retractors  and  the  strips  inserted 
around  the  cut,  between  the  parietal  peritoneum  and  intes- 
tines and  to  a  distance  of  three  inches  from  the  wound. 
Strips  of  gauze  are  passed,  when  possible,  below  the 
appendix  to  prevent  entrance  of  infected    material  into  the 

"^  Jour.  Amer.  Med.  Assoc. ^  February  20,  1S97. 


A  BD  OMINA  L    SE  CTION. 


817 


pelvis,  and  a  piece  is  pushed  upward  toward  the  liver 
(Van  Hook).  Over  the  iodoform  gauze  which  it  may  be 
necessary  to  leave  in  place  after  the  operation,  gauze  pads 
are  packed.  The  appendix  is  sought  for  by  finding  the 
colon.  The  colon  is  found  by  following  the  parietal  perito- 
neum with  the  finger.  The  course  of  the  finger  is  first  out- 
ward, next  backward,  and  finally  inward ;  the  first  obstruc- 


FiG.  271. — Resection  of  the  vermiform  appendix,  incision  through  the  abdominal  wall 
(Kocher)  :  a,  external  oblique  muscle  ;  k,  internal  oblique  muscle ;  c,  aponeurosis  of  external 
oblique  ;  d,  aponeurosis  of  internal  oblique  ;  e,  peritoneum  ;  f,  outer  border  of  rectus  abdom- 
inis muscle  (under  it  the  deep  epigastric  vessels). 


tion  it  encounters  is  the  colon.  The  fact  that  it  is  the  colon 
can  be  confirmed  by  finding  the  longitudinal  band.  The 
longitudinal  band  leads  directly  to  the  appendix.  Pass  the 
finger  down  to  the  head  of  the  colon,  find  the  appendix, 
usually  posterior  and  internal,  and  lift  it  and  the  head  of  the 
colon  into  the  wound.  In  some  cases  it  will  be  advisable  to 
dehver  the  head  of  the  colon  from  the  belly ;  in  other  cases 

52 


8l8      DISEASES  AND   INJURIES   OF  THE  ABDOMEN. 


this  will  not  be  necessary.  If  adhesions  exist,  they  must  be 
gently  and  carefully  broken  down.  In  most  cases  the  meso- 
appendix  And  neck  of  the  appendix  are  tied  with  two  strong 
silk  ligatures  (P^ig.  272),  are  cut  off  below  the  ligatures,  and  the 
stump  of  the  appendix  is  cauterized  with  pure  carbolic  acid 


Fig.  272. — Ligation  of  appendix  and  meso-appendi.x. 

and  is  inverted  into  the  coats  of  the  colon  by  Lembert  sutures. 
An  excellent  method  is  to  turn  up  a  cuff  of  peritoneum,  pull 
down  the  other  coats,  ligate  at  the  base,  cut  through  the 
tube,  let  the  musculomucous  stump  retract,  and  tie  or  suture 
the  fieritoneal  cuff  over  the  stump.     This  plan  was  devised 

by  Barker  (Fig.  273).     Another 
method  is  to  encircle  the  appendix 
W'ith  a  ligature,  as  is  shown  in  Fig. 
j    I         '2-T2,  pass  the  second  ligature  through 
\    I  the  meso-appendix  at  x,  tie  both  liga- 

tures, cut  off  the  appendix  and  meso- 
pj^^^^^l      appendix  below  the  threads,  suture 
^'^^^-—^    ^'      the    fringe    of    the    meso-appendix, 
and  cauterize  and  invert  the  stump 
of  the  appendix.     Some  remove  the 
appendix   by    an    elliptical  -incision 
around  its  base,  and  close  the  colon- 
„  ,    ,      ,_  .     ,     wound  bv  Lembert  sutures.     Some 

Fig.   273. — Barkers  technic   of  /   i       i  r    i         i-  •        i 

operation  for  removal  of  the  appen-        SUrrOUnd  the  baSC  OI  the  dlVCrtlCUlum 

with  a  purse-string  suture,  cut  off 
the  appendix  close  to  the  colon,  invaginate  the  stump  into 
the  lumen  of  the  colon,  tie  the  purse-string  suture,  and  suture 
the  peritoneal  surfaces  of  the  colon  together.  If  there  is  no 
pus  or  no  extravasated  feces,  if  the  peritoneum  is  not  sen- 


1- 


I 


S^ 


ABDOMINAL    SECTION.  819 

ously  affected,  if  the  appendix  is  not  gangrenous  or  perfo- 
rated, and  if  there  is  no  pus  within  the  appendix,  remove  the 
pads,  irrigate  with  hot  salt  solution,  remove  the  strips  of 
gauze,  and  close  the  wound.  If  any  of  the  above  conditions 
were  found,  remove  the  infected  pads,  but  leave  the  iodoform 
strips  in  place  to  limit  infection  and  secure  drainage.  Pass 
sutures  through  the  wound-edges,  tie  some  of  the  sutures 
and  leave  some  untied  until  the  gauze  is  removed  at  a  later 
period  (Van  Hook). 

If  an  operation  is  performed  in  a  distinct  interval,  pus  is 
absent  and  the  surgeon  can  proceed  without  apprehension. 
If  there  is  any  question  of  the  presence  of  pus,  surround  the 
region  with  gauze,  as  suggested  above,  before  breaking  down 
adhesions  and  liberating  the  appendix.  An  interval  operation 
should  not  be  performed  until  three  weeks  after  an  attack. 
In  an  interval  case  McBurney  proceeds  as  follows  :  he  makes 
the  skin  incision  in  the  direction  of  the  inbers  of  the  external 
obUque  muscle,  separates  the  fibers  of  this  muscle  by  blunt 
dissection,  retracts  them,  separates  the  fibres  of  the  internal 
oblique  and  the  transversalis  muscles  in  the  same  way  and  re- 
tracts them,  and  opens  the  transversalis  fascia  and  peritoneum. 
No  muscle-fibers  are  cut,  and  hernia  is  not  apt  to  follow. 
Such  a  wound  is  closed  as  follows  :  a  continuous  catgut 
suture  for  the  peritoneum,  sutures  of  kangaroo-tendon  for 
transversalis  fascia,  the  muscles  are  restored  to  place,  and 
the  skin  is  closed  by  a  subcuticular  stitch. 

If  an  abscess  is  believed  to  exist,  make  an  incision  parallel 
with  Poupart's  ligament  and  over  the  area  of  dulness  on 
percussion  (Willard  Parker's  oblique  incision).  If  the  abscess 
is  adherent  to  the  anterior  abdominal  wall,  such  an  incision 
will  not  enter  the  free  peritoneal  cavity.  If  after  opening  the 
abdomen  an  abscess  is  thought  to  exist,  although  it  is  not 
adherent  to  the  anterior  abdominal  wall,  surround  the  abscess 
w^ith  gauze  before  opening  it,  as  directed  under  acute  appen- 
dicitis. This  gauze  is  placed  under  the  margins  of  the  inci- 
sion in  the  peritoneum  all  around  the  appendix  area ;  a  piece 
is  carried  toward  the  pelvis  and  another  piece  toward  the  liver. 
Overlay  this  gauze  with  gauze  pads  (Van  Hook).  Adhesions 
are  broken  through  with  the  finger,  and  when  pus  appears  it 
is  at  once  wiped  away.  Remove  the  appendix  in  most  cases, 
but  not  in  all.  If  the  appendix  lies  loose  in  the  abscess-cavity, 
if  it  is  sloughed  off  or  but  loosely  attached  to  the  abscess- 
wall,  remove  it.  If  the  appendix  is  firmly  fixed  in  the  abscess- 
wall  and  must  be  dug  out  of  a  mass  of  inflammator>'  mate- 
rial, do  not  remove  it.     To  remove  it  under  these  circum- 


820      DISEASES  AXD    INJURIES   OF  THE  ABDOMEN. 

stances  may  rupture  the  wall  and  disseminate  the  pus  into 
regions  not  proteated  by  pads  and  gauze.  Deaver,  Murphy, 
and  others  tell  us  to  always  remove  the  appendix.  We  do 
not  believe  this  to  be  a  safe  rule  to  follow.  To  insist  on 
removing  the  appendix  may  cause  death.  When  the  appen- 
dix is  left  it  usually  sloughs  away.  It  is  true  a  fecal  fistula 
may  result,  but  this  usually  heals  spontaneously.  Even  if  a 
fecal  fistula  forms  and  does  not  heal,  the  surgeon  may  have 
acted  properly  in  not  removing  the  appendix,  because  a  fecal 
fistula  may  be  remedied  by  another  operation.  It  is  rarely 
that  secondary  abscess  forms,  and  there  are  not  a  great  many 
cases  recorded  in  which  an  appendix  has  subsequently  given 
trouble  when  left  after  operation.  ''"*  When  Deaver  decides  to 
remove  such  an  appendix  he  makes  an  incision  in  the  median 
line  of  the  abdomen,  packs  around  the  periphery  of  the 
abscess  with  gauze,  opens  the  abscess  by  another  incision, 
disinfects,  inserts  drainage,  and  then  removes  the  surround- 
ing gauze  and  closes  the  median  incision. "  Irrigation  should 
not  be  employed  in  appendicular  abscess.  The  force  of  the 
stream  may  break  down  barriers  of  lymph  and  spread  infec- 
tion. After  the  evacuation  of  the  pus,  whether  the  appendix 
was  removed  or  not,  take  out  the  pads,  but  leave  the  long 
strands  of  iodoform  gauze  in  place  (Van  Hook).  Introduce 
iodoform  gauze  into  the  abscess-cavity  and  insert  a  rubber 
tube,  partially  suture  the  wound,  and  dress  with  dry  gauze. 
In  forty-eight  hours  all  the  gauze  is  removed  and  fresh  pieces 
are  inserted  for  drainage.  After  this  period  the  gauze  drain 
is  changed  daily.  An  interval  case  should  be  up  and  about 
in  from  ten  days  to  two  weeks  after  operation.  An  abscess 
case  may  require  a  much  longer  time  for  complete  recovery. 
A  fecal  fistula  sometimes  results  in  cases  in  which  the  appen- 
dix was  not  removed,  and  occasionally  forms  when  it  was 
removed.  Morris  maintains  and  proves  that  these  large 
pieces  of  iodoform  gauze  sometimes  cause  intestinal  obstruc- 
tion and  sometimes  iodoform-poisoning,  but  the  risk,  it  seems 
to  us,  should  be  taken. 

Bnterorrhaphy,  or  Suture  of  the  Intestine. — Sur- 
gical opinion  has  greatly  altered  in  regard  to  this  oper- 
ation since  the  day  when  John  Bell  wrote  his  famous  attack 
on  Benjamin  Bell.  John  Bell  said :  "  If  in  all  surgery  there 
is  a  work  of  supererogation,  it  is  this  operation  of  sewing  up 
a  wounded  gut."  To-day  we  know  that  if  in  all  surgery 
there  is  a  proceeding  of  imperative  necessity,  it  is  the  sewing 
up  of  a  wound  in  the  intestine.  To  perform  this  operation 
take  fine  sterile  silk  and  thread  a  thin,  round,  straight  calyx- 


EXTEKORRHAPIIY,    OR   SUTURE    OF   THE   INTESTINE.   82 1 

eyed  needle  with  it  (Fig-.  274).  This  needle  is  very  useful, 
as  it  can  be  threaded  rapidly  by  pushing  the  calyx  eye  down 
upon  the  silk  thread  while  the  latter  is  kept  taut.  Lanberfs 
suture  (Fig.  275,  a)  is  at  right  angles  to  the  wound.  It  goes 
down  to,  but  not  through,  the  mucous  membrane.  It  is 
formed  by  picking  up  a  fold  of  the  intestine  (one-twelfth 
to  one-eighth  of  an  inch  wide)  one-eighth  of  an  inch  from 
the    edge    on    one   side    of  the    wound,  passing  the  needle 


Fig.  274.— Eye  of  the 
calyx-eye  needle. 


Fig.  275. — Enterorrhaphy  :  a,  Lembert's  suture  ;  B,  Dupuytren's 
suture. 


through,  picking  up  a  fold  on  the  opposite  side  of  the 
wound,  and  passing  the  needle  through.  On  tying  the 
threads  the  serous  membrane  is  inverted  and  peritoneum 
is  brought  into  contact  with  peritoneum.  For  many  years 
it  was  taught  that  this  suture  should  include  only  the  serous 
coat,  but  Halsted,  in  1887,  showed  that  it  must  include  the 
tough  submucous  coat.  The  submucous  coat  is  strong,  and 
wild  hold  a  suture.     The  other  coats  are  thin,  tear  easily,  and 


Fig.  276. — Cushing's  right-angled  suture  (Senn). 

will  not  hold  a  suture.  So  thin  are  the  coats  that  a  surgeon 
could  not  suture  the  serous  coat  alone  were  he  to  try. 
Sutures  which  include  only  the  muscular  and  serous  coats  tear 
out  easily.  Dupuytren's  suture  (Fig.  274,  b)  is  simply  a  con- 
tinuous Lembert  suture  running  obliquely  across  the  wound. 
Cus/mtg's  right-angleei suture  (Fig.  276)  is  a  continuous  suture 


822      DISEASES  AND   INJURIES    OF   THE   ABDOMEN. 

catching  up  the  submucous  coat  and  serving  to  invert  the 
serous  layer.  Ford  of  San  Francisco  employs  a  continuous 
inversion  suture,  which  is  tied  in  a  single  knot  each  time  it  is 


Fig.  277. Ford's  stitch,  showing  a  Lembert  insertion  and  the  needle  passed  so   as   to  tie  a 

single  knot  by  drawing  it  on  through. 


_-      1  -f 


_-      )  ^ 


:: ) 


drawn  through  (Fig.  277).     Downes  of  Philadelphia  uses  a 
similar  stitch,     Halsted's  mattress  or  quilt  suture  is  shown 

in  Fig.  278.  Each  stitch  picks 
up  the  submucous  coat.  Mat- 
tress sutures  do  not  tear  out 
easily,  they  oppose  evenly  con- 
siderable surfaces,  and  do  not 
constrict  the  tissue  as  much  as 
Lembert  stitches.  The  Czerny- 
Lcmbert  suture  is  a  suture  passed 
through  the  serous  membrane 
on  one  side  of  the  wound,  made 
to  perforate  the  mucous  mem- 
brane, and  to  emerge  at  a  corre- 
sponding point  of  the  serous  mem- 
brane. A  Lembert  suture  is  added 
(Fig.  279).  As  at  present  used,  the 
Czerny  suture  is  carried  to,  but  not  through,  the  mucous 
membrane.  Gussenbauer's  is  similar  to  the  Czerny-Lembert 
suture,  except  that  it  applies  the  Czerny  and  the  Lembert 
with  one  suture,  and  this  suture  does  not  pass  through  the 
mucous  membrane  (Fig.  281).  Wdlfler''s  suture  unites  broad 
layers  of  the  serous  coat,  the  knots  being  tied  internally  (Fig. 
282).  Senn  says  that  after  suturing  a  large  wound  of  the 
stomach  or  of  intestine  a  strip  of  omentum  ought  to  be  laid 


Fig.  278. — A,  Halsted  sutures  untied  ; 
B,  Halsted  sutures  tied  and  serous  sur 
face  inverted. 


DIGITAL   DILATATION  OF  PYLORUS,    ETC. 


over  the  wound  and  fastened  b}-  catgut  sutures  (omental 
graft).  These  grafts  adhere  and  are  a  safeguard  against  leak- 
age. For  other  methods  of  enterorrhaphy,  see  Intestinal 
Resection  and  Anastomosis. 


Fig. 


-Czerny-Lembert  suture. 


Fig. 


D. — Czerny-Lembert  suture  as  at 
present  used. 


Fig.  281. — Gussenbauer's  suture. 

Digital  Dilatation  of  Pylorus  for  Cicatricial  Ste- 
nosis (I/Oreta'S  Operation). — For  a  week  before  operation 
feed  the  patient  by  way  of  the  rectum,  and  supplement  rectal 
feeding     by     the      stomach      ad- 
ministration   of    peptonized    milk. 
Wash    out    the    stomach    once    a 
day.     A  few  hours  before  opera- 
tion wash  out  the  stomach  again. 
Place  the  patient  recumbent   and 
administer  ether.     Make  a  vertical 
incision  in  the  linea  alba.     The  in- 
cision begins  one  inch  below  the 
ensiform  cartilage  and   should  be 
five  inches  in  length.     \Mien  the 
peritoneum  has   been  opened  the 

stomach  is  drawn  out  of  the  wound,  any  adherent  omentum 
is  separated,  and  the  pylorus  is  carefully  examined.  The 
stomach,  after  being  surrounded  with  gauze  pads,  is  opened 
near  the  center  of  its  anterior  surface,  "  but  rather  nearer  to 
its  pyloric  end  "  (Jacobsonj. 


Fig.  282. — Wijlfler's  suture. 


824      DISE.tSES  AXD   INJURIES   OF   THE   ABDOMEN. 

Insert  the  index-finger  tlirough  the  stomach  wound  and 
into  the  pylorus,  and  follow  that  with  the  middle  finger. 
The  pylorus  can  be  well  dilated  by  separating  the  fingers.  If 
the  stenosis  is  so  tight  as  to  pre\ent  the  entry  of  a  finger, 
first  introduce  a  pair  of  hemostatic  forceps  and  open  the 
blades  a  little  when  they  are  within  the  lumen  of  the  con- 
stricted area.  The  wound  in  the  stomach  is  closed  by  a 
continuous  silk  suture  of  the  mucous  membrane  and  two 
layers  of  Halsted  sutures,  to  invert  and  approximate  the  peri- 
toneal surfaces.  After  closure  of  the  stomach  wound  the 
abdominal  wound  is  sutured. 

Pyloroplasty  (Keineke-Mikulic^  Operation). — Pre- 
pare the  patient  as  for  Loreta's  operation.  Open  the  ab- 
domen in  the  middle  line.  Draw  up  the  pylorus  as  well  as 
possible  and  pack  hot  moist  gauze  pads  around  it ;  make  an 
incision  through  the  stricture  and  in  a  direction  correspond- 
ing to  the  long  axis  of  the  stomach  and  bowel.  Catch  an 
aneurysm-needle  under  the  upper  margin  of  the  incision  and 
draw  it  up,  and  an  aneurysm-needle  over  the  lower  margin 
and  draw  it  down.  The  effect  of  traction  is  to  convert  the 
transverse  wound  into  a  vertical  one.  The  sutures  are 
applied  so  as  to  maintain  the  wound  in  a  vertical  line.  The 
mucous  membrane  is  sutured  with  a  continuous  suture  of 
silk,  and  interrupted  Halsted  sutures  of  silk  close  the  peri- 
toneal and  muscular  coats. 

Pylorectomy  (Excision  of  the  Pylorus). — The  re- 
moval of  a  portion  of  the  stomach  is  a  partial  gastrectomy, 
and  pylorectomy  is  a  partial  gastrectomy  in  which  the  pylorus 
is  removed. 

This  operation,  which  was  first  performed  by  Pean  in 
1879,  is  done  for  cancer  of  the  pylorus.  In  most  cases  of 
pyloric  cancer  the  abdomen  is  opened  after  a  palpable  tumor 
is  detected,  and  when  a  palpable  tumor  is  detectable  it  is 
usually  too  late  to  perform  pylorectomy.' 

Keen  agrees  with  Hemmeter  that  stenotic  symptoms,  even 
when  no  tumor  is  palpable,  call  for  exploratory  laparotomy ; 
if  the  stomach  is  dilated,  if  there  is  cachexia,  if  there  is  no 
free  hydrochloric  acid  in  the  gastric  juice,  if  there  is  an  excess 
of  lactic  acid  in  the  gastric  juice,  if  the  patient  is  at  or  beyond 
forty  years  of  age,  when  there  is  vomiting  of  blood,  when 
the  Oppler  bacillus  is  present,  when  blood  examination  shows 
a  diminution  in  red  corpuscles  and  hemoglobin,  and  also 
shows  that  there  is  no  increase  in  white  corpuscles  after  a 
full  meal.     After  the  abdomen  has  been  opened  the  stomach 

'  Keen's  Caj-tzvrigkt  Lectures  for  1S98. 


P  YL  ORECTOMY.  825 

is  examined,  and  if  a  tumor  exists  the  surgeon  must  decide 
between  the  performance  of  pylorectomy  and  gastro-enteros- 
torn}-.  If  the  tumor  is  not  very  extensive,  if  there  is  no 
glandular  involvement  or  only  involvement  which  can  be 
removed,  and  if  adhesions  are  not  extensive,  pylorectomy  is 
chosen,  otherwise  gastro-enterostomy  is  selected. 

Even  in  favorable  cases  the  mortality  from  p}-lorectom}'  is 
over  25  per  cent.  Prepare  the  patient  for  pj'lorectomy  as  for 
Loreta's  operation.  The  best  incision  through  the  abdominal 
wall  is  transverse  over  the  middle  of  the  tumor.  A  small 
incision  is  made  first  to  permit  of  exploration,  and  if  the 
growth  is  found  to  be  removable  the  incision  is  enlarged. 
The  center  of  the  incision  is  over  the  most  prominent  part 
of  the  tumor,  and  the  direction  of  the  incision  corresponds 
with  the  long  axis  of  the  pylorus.  Draw  the  tumor  into 
the  wound,  and  tuck  pads  about  the  stomach  and  the 
pylorus  to  catch  extravasated  fluids.  Free  the  pylorus ; 
incise  between  forceps  the  great  omentum  near  the  greater 
curvature  of  the  stomach,  and  ligate  each  end  in  segments  ; 
treat  the  lesser  omentum  in  the  same  manner.  Each 
omentum  is  di\ided  only  to  an  extent  sufficient  to  permit 
removal  of  the  growth.  Repack  the  gauze  pads  and  tie  a 
rubber  tube  around  the  duodenum  below  the  growth.  In 
making  the  excision  remember  that  the  stomach-wound  will 
be  much  larger  than  the  duodenal  wound,  and  a  special 
method  of  suturing  will  be  required  to  approximate  the  two 
wounds  in  size.  The  lines  of  incision  are  shown  in  Fig.  i'^^. 
The  stomach  is  cut  with  scissors  until 
two-thirds  of  its  depth  is  divided,  and 
the  organ  is  washed  out.  After  stop- 
ping hemorrhage  this  cut  is  closed  by 
a  continuous  suture  for  the  mucous 
membrane  and  b\-  Halsted  sutures 
for  the  other  coats.  The  remaining 
portion  of  the  stomach  is  cut  through. 
The  duodenum  is  cut  through  its  fig.  283.-Pyiorectomy. 
upper  half  below  the  growth,  and  is 
fastened  to  the  stomach  by  Halsted  sutures  at  the  upper 
border  and  Wolfler's  sutures  at  the  posterior  borders.  W'ol- 
fler's  sutures  are  applied  from  inside,  they  pierce  all  coats, 
and  bring  broad  layers  of  the  serous  coat  into  apposition. 
The  remainder  of  the  duodenum  is  cut  through,  and  its  ante- 
rior and  inferior  parts  are  united  to  the  stomach  by  a  double 
row  of  Halsted  sutures,  as  set  forth  above  (Fig.  283V  Stitch 
the   edsres   of  the   cut   omenta  to  the  stomach,  cleanse  the 


826      DISEASES  AND   INJURIES   OF   THE  ABDOMEN. 

parts,  replace  the  stomach,  insert  gauze  for  drainage,  close 
the  abdominal  incision,  and  dress  the  wound.  Drainage  is 
necessary  after  any  extensive  operation  upon  the  stomach 
because  there  is  great  danger  of  extravasation,  this  danger 
being  due,  as  Richardson  shows,  to  the  difficulty  of  making 
a  tight  approximation  and  to  the  action  of  the  gastric  juice. 
Another  method  of  performing  pylorectomy  is  to  excise  the 
growth  as  directed  above,  suture  the  opening  in  the  stomach 
and  implant  the  duodenum  in  the  anterior  or  posterior  wall  of 


Fig  284  — Kocher's  method  of  pylorectomy  :  L,  liver ;  D,  duodenum  ;  P,  pylorus  ;  C, 
carcinoma  ;  T  C,  transverse  colon  ;  a,  separation-place  of  the  ligature  gastrocolicum  ;  6,  sep- 
aration-place of  the  lesser  omentum  ;  c,  separation-line  of  the  stomach;  </,  place  where  the 
stomach  is  kept  closed  by  the  middle  and  index  fingers. 

the  stomach,  making  an  incision  through  the  stomach-wall  to 
permit  of  it.  Kocher  advocates  implantation  of  the  duode- 
num in  the  posterior  wall  of  the  stomach.  Kocher's  method 
of  pylorectomy  is  shown  in  Figs.  284,  285.  The  junction 
between  the  duodenum  and  the  posterior  Avail  of  the  stomach 
may  be  effected  by  a  large  Murphy  button.  Give  nothing  by 
the  mouth  for  twenty-four  hours  after  the  performance  of 
pylorectomy.  Thirst  can  be  relieved  by  enemata  of  water 
or  by  the    hypodermatic   injection    of  boiled   water.     After 

*  M.  H.  Richardson,  in  Boston  Med.  and  Surg.  Jour.,  August  4,  1898. 


GASTKOTOMV. 


827 


twenty-four  hours  begin  with  stomach  feeding,  starting  with 
dessertspoonful-doses  of  peptonized  milk  every  hour. 

Total  Gastrectomy. — The  entire  stomach  was  first  re- 
moved by  Conner  of  Cincinnati.  The  first  successful  opera- 
tion was  performed  by  Schlatter  of  Zurich  in  189S.  Total 
gastrectomy  will  rarely  be  required,  but  in  certain  unusual 
cases  it  will  be  proper  to  perform  it.  In  some  cases  the 
duodenal  end  can  be  sutured  to  the  divided  esophagus ;  in 
others  it  will  be  necessar}'  to  close  the  end  of  the  divided 


Fig.  2S5. — Kocher's  method  of  pylorectomy :  Z>,  duodenum  at  the  posterior  wall;  a, 
continuous  suture  of  the  peritoneum  ;  b,  posterior  line  of  peritoneal  continuous  suture  of  the 
ring ;  /,  assistant's  thumb  pressing  the  stomach  against  the  duodenum  so  as  to  close  its  lumen  ; 
i,  incision  in  the  posterior  gastric  wall. 


first  portion  of  the  duodenum,  and  anastomose  the  esopha- 
gus to  the  third  portion  of  the  duodenum. 

The  cases  suitable  for  total  gastrectom\-  are  those  in  which 
the  entire  viscus,  or  almost  the  entire  viscus  is  cancerous,  the 
stomach  being  still  freely  movable,  and  the  glands  not  so 
much  implicated  as  to  forbid  attempts  at  removal.  It  is  a 
remarkable  fact,  first  demonstrated  in  Schlatter's  case,  that  an 
individual  can  digest  food  xtxy  well  without  a  stomach. 

Gastrotomy. — This  term  is  used  to  designate  the  opera- 
tion of  opening  the  stomach  for  the  accomplishment  of  some 
purpose,  and  immediately  closing  the  incision  in  the  gastric 


828      DISEASES  AND    INJURIES    OE   THE   ABDOMEN. 

wall  when  that  purpose  is  accomplished.  Gastrotomy  may- 
be performed  to  permit  of  the  removal  of  foreign  bodies,  of 
exploration  of  the  stomach  and  its  extremities,  of  divulsion 
of  the  pyloric  orifice,  of  the  treatment  of  an  esophageal 
stricture,  or  a  stricture  of  the  cardiac  orifice  of  the  stomach, 
or  of  the  removal  of  a  foreign  body  lodged  in  the  esophagus. 

The  patient  is  prepared  as  for  pylorectomy.  The  incision 
may  be  vertical  in  the  middle  line  or  identical  with  the 
incision  for  pylorectomy.  If  a  large  foreign  body  can  be 
felt,  the  incision  is  made  directly  over  it.  When  the 
peritoneal  cavity  is  opened  the  surgeon  decides  as  to  the 
point  where  the  stomach  is  to  be  incised,  and  draws  this  por- 
tion out  through  the  wound,  packing  gauze  pads  under  and 
around  it.  The  stomach  is  opened  by  means  of  scissors,  the 
cut  being  at  a  right  angle  to  the  long  axis  of  the  viscus 
(Jacobson).  Bleeding  vessels  are  ligated  with  catgut.  The 
purpose  for  which  the  stomach  was  opened  is  now  to  be  car- 
ried out,  the  interior  of  the  stomach  and  the  surface  of  the 
extruded  portion  are  irrigated  with  hot  salt  solution,  the  mu- 
cous membrane  is  sutured  with  a  continuous  suture  of  silk  and 
two  rows  of  Halsted  sutures  are  inserted.  The  abdominal 
wound  is  closed  without  drainage. 

Gastrostomy  is  the  making  of  a  permanent  gastric  fistula, 
through  which  opening  the  patient  can  be  fed.  The  opera- 
tion is  employed  in  cases  of  esophageal  obstruction  or  ob- 
struction of  the  cardiac  end  of  the  stomach.  In  many  cases 
of  malignant  disease  the  operation  is  performed  too  late,  and 
if  performed  when  the  patient  is  greatly  emaciated  and  ex- 
hausted the  operation  has,  of  course,  a  high  mortality.  An 
early  operation  is  far  safer  and  confers  the  maximum  of  relief. 
The  operation  should  be  performed,  as  Mikulicz  advises,  when 
the  patient  is  steadily  losing  weight  and  there  is  beginning  to 
be  difficulty  in  swallowing  semi-solids  or  liquids.  The  sur- 
geon must  endeavor  to  perform  an  operation  which  will  not 
permit  of  leakage.  Prepare  the  patient  as  for  gastrotomy. 
In  Witzel's  method  an  incision  is  made  four  inches  long,  run- 
ning to  the  left  from  the  middle  line,  just  below  the  border 
of  the  ribs.  After  opening  the  peritoneal  cavity  seize  the 
stomach,  bring  it  out  of  the  wound,  and  pack  gauze  around 
it.  Introduce  a  rubber  tube  into  the  stomach  and  enfold  it 
by  a  double  row  of  Lembert  sutures  (Figs.  286,  287).  This 
tube  should  be  five  inches  long  and  of  the  same  diameter  as  a 
No.  25  French  bougie.  The  opening  is  made  in  the  stomach 
toward  the  cardiac  extremity,  the  tube  is  placed  parallel  with 
the  belly-wound,  and  the  outer  end  of  the  tube  emerges  in 


GASTROSTOMY. 


829 


the  median  line.  The  stomach  is  returned,  and  is  stitched 
by  three  sutures  to  the  abdominal  wall.  The  tube  is  retained 
in  place  b\-  a  catgut  stitch  through  the  wall  of  the  tube  and 
the  stomach-wall.  The  abdominal  incision  is  sutured  and  a 
clamp  is  placed  on  the  tube.  When  the  patient  is  fed  a  fun- 
nel is  slipped  into  the  tube,  the  clamp  is  removed,  and  liquid 
food  is  poured  into  the  funnel.  After  the  wound  heals  it  is 
not  necessary  to  permanently  retain  the  tube.     It  is  passed 


\ 


i^to^u 


■^s 


tiG.  286. — Vv'itzel's  method  for  g^astros- 
tomy,  showing  application  of  sutures  in 
■wall  of  stomach,  embedding  tube  ob- 
liquely therein. 


Fig.  2S7.— Sutures   tied,   completely   embed- 
ding tube  for  some  distance. 


when  the  patient  desires  food.  Kader  has  modified  Witzel's 
method.  A  small  incision  is  made  in  the  stomach  and  a  tube 
is  introduced.  Two  Lembert  sutures  are  passed  so  as  to 
form  a  fold  on  each  side  of  the  tube  and  turn  the  stomach- 
wall  inward  around  the  tube.  Lembert  sutures  are  inserted 
in  the  furrow  on  each  side  of  the  tube.  Two  more  folds  are 
formed  over  the  first  two.  The  stomach-wall  is  stitched  to  the 
parietal  peritoneum  and  sheath  of  the  rectus  muscle  (Willy 
IMeyer).  The  Ssabanejew-Frank  operation  is  preferred  by 
many  surgeons.     Fenger's  incision  is  made  (a  curved  incision 


830      DISEASES  AND   INJURIES    OF   THE   ABDOMEN. 


at  the  margin  of  the  costal  cartilages  of  the  left  side).  A  cone 
of  the  stomach  is  pulled  out  of  the  wound  and  is  passed  under 
a  bridge  of  skin  which  has  been  prepared  for  it.  The  stomach 
is  fixed  above  the  margin  of  the  ribs  and  opened  (Figs.  288, 
289).     Van  Hacker  makes  the  gastric  fistula  through  the  left 

rectus  muscle,  and  Hahn 
between  two  of  the  rib 
cartilages  (Willy  I\'Ieyer). 
Emanuel   Senn    devised 


Figs.  288,  289. — Frank's  method  of  gastrostomy  in  carcinoma  of  the  esophagus. 


the  following  method  :  a  cone  of  the  stomach  is  pulled  out 
of  the  abdominal  wound,  and  this  cone  is  puckered  by  the 
insertion  of  two  drawing-string  sutures  of  chromic  catgut 
through  the  serous  and  muscular  coats.  A  cuff  of  gastro- 
colic omentum  is  sutured  by  silk  around  the  neck  of  the 
puckered  cone.  The  stomach  is  sutured  to  the  belly-wall 
with  silk,  the  sutures,  including  the  omental  cuff,  the  serous 
and  muscular  coats  of  the  stomach,  and  the  structures  of 
the  belly-wall,  except  the  skin.  The  skin  is  partly  sutured. 
The  stomach  may  be  opened  at  any  time. 

Gastro- enterostomy  or,  g-astro-jejunostomy  is  the 
establishment  of  a  permanent  fistula  between  the  stomach 
and  the  small  intestine,  in  order  to  side-track  the  pylorus. 
The  operation  is  performed  for  cancer  of  the  pylorus,  for 
non-cancerous  stenosis  of  the  pylorus,  and  in  some  cases  of 
ulcer  of  the  stomach.  Gastro-enterostomy  w^as  first  per- 
formed by  Wolfler  in  1881.  In' non-maHgnant  conditions 
the  mortality  is  very  low  (about  4  per  cent.),  the  hyperacidity 
of  the    gastric  juice   disappears    and   the    functions    of    the 


GASTRO-EA'TEROSTOMY   OR    GASTRO-JEJUNOSTOMY.    83 1 

stomach  are  restored.  In  malignant  cases  the  mortality  is 
higher,  but  even  in  such  cases  life  may  be  prolonged  and 
made  comfortable  for  months  by  the  operation.  Before 
operating  the  stomach  must  be  irrigated  as  before  pylorec- 
tomy. 

Anterior  Gastro -enterostomy. — In  Senn's  method  of 
operation  a  median  incision  is  made  through  the  abdominal 
wall,  from  below  the  xiphoid  cartilage  to  the  umbilicus.  An 
opening  is  made  in  the  stomach  in  the  direction  of  the  long 
axis  of  the  viscus  and  its  edges  are  stitched  with  a  continuous 
catgut  suture.  The  contents  of  the  bowel  are  forced  along  to 
below  the  point  where  an  incision  is  to  be  made ;  a  rubber 
tube  is  fastened  around  the  bowel  above  this  point,  and 
another  below  it ;  an  incision  is  made  in  the  long  axis  of  the 
bowel,  and  the  margins  of  the  wound  are  sutured  in  the 
same  manner  as  the  stomach-wound. 
Bone  plates  are  introduced  into  the 
stomach  and  intestine,  and  the  liga- 
tures are  tied  as  in  intestinal  anasto- 
mosis. Catgut  rings  or  rubber  rings 
may  be  used.  Fig.  290  shows 
Wolfler's  method  of  gastro-enteros- 
tomy.  Kocher's  method  is  as  follows : 
after  opening  the  abdomen,  lift  up 
the  omentum,  pull  up  a  loop  of  '"'''•  Ta^e^^erl!"'"'""'' 
intestine    and    find   the    point  where 

the  jejunum  appears  from  under  the  mesocolon.  Select  a 
loop  sixteen  inches  from  the  origin  of  the  jejunum  and 
prepare  to  attach  it  to  the  stomach.  Wolfler  showed  that 
the  intestine  should  be  applied  to  the  stomach  in  such  a 
manner  that  the  direction  of  peristalsis  in  the  bowel  must 
correspond  to  the  direction  of  the  stomach-tide.  This  can 
be  accomplished  by  having  the  proximal  portion  of  gut  to 
the  left,  and  the  distal  portion  to  the  right.  The  operation  is 
to  be  so  performed  that  after  its  completion  the  stomach-con- 
tents pass  into  the  distal  portion  of  the  gut,  and  the  intestinal 
contents  do  not  tend  to  enter  the  stomach  (Fig.  293).  In  order 
to  accomplish  this  Kocher  hangs  the  intestine  to  the  stomach- 
wall  in  such  a  manner  that  the  proximal  portion  of  the  loop 
is  posterior  and  ascending,  and  the  distal  portion  is  anterior 
and  descending.  The  bowel  is  hung  to  the  stomach  by  a 
continuous  serous  suture  of  silk,  the  ends  of  which  are  left 
long.  The  intestine  is  opened  by  a  curved  incision,  the 
convexity  of  which  is  downward.  The  stomach  is  opened  so 
that  the  convexity  of  the  cut  is  upward.     The  valve-like  pro- 


832      DISEASES  AND   INJURIES   OF  THE  ABDOMEN. 

tion  of  the  bowel-wall  is  sutured  to  the  stomach  below  the 
incision  in  that  viscus.  The  two  openings  are  well  approxi- 
mated by  sutures.  In  some  cases  after  the  performance  of 
gastro-enterostomy  fluid  from  the  stomach  gathers  in   the 


Fig.  291. — Jaboulay's  method  of  gastro-enterostomy. 

proximal  loop  and  persistent  vomiting  of  bile  occurs.  This  con- 
dition is  ver>''  serious  and  often  fatal,  and  may  be  due  to  bend- 
ing or  twisting  of  the  distal  loop,  to  failure  of  peristalsis  in 
the  proximal  loop,  or  to  contraction  of  the  stomach  incision.^ 


Fig.   292. — Braun's  method  of  gasiro-enterostomy. 

In  some  cases  a  vicious  circulation  is  established,  some  or 
all  of  the  stomach  contents  passing  through  the  fistula  and 

1  Chlumsky  on  gastro-enterostomy  in  the  Breslau  clinic.      Article  by  Charle.s 
L.  Gibson,  in  Annals  of  Surgery,  August,  1898. 


GASTKO-ENTEROSrOMY   OK    GASTRO-JEJUNOSTOMY.    833 

into  the  proximal  loop.  The  above  condition  can  be 
corrected  or  prevented  by  performing  an  anastomosis 
between  the  two  loops  (Figs.  291,  292).  It  is  stated  that 
such  unfortunate  conditions  do  not  follow  posterior  gastro- 
enterostomy, and  are  rare  after  the  Wolfler-Lucke  operation 
(Fig.  293). 

Posterior  gastro-enterostomy  is  performed  as  follows  : 
after  the  abdomen  has  been  opened  the  stomach  and  omen- 
tum are  raised;  a  portion  of  the  upper  jejunum  is  seized, 
emptied,  and  tied  with  tubes  as  previously  described.  A 
spot  is  selected  on  the  transverse  mesocolon  where  there  are 
no  vessels  and  an  opening  is  made  through  the  mesocolon 
with  a  dry  dissector.     The  posterior  wall  of  the  stomach  is 


Fig.  293. — Wolfler-Lucke  method  of  gastro-enterostoiii>  . 

pulled  into  the  opening  and  sutured  to  its  edges.    An  anasto- 
mosis is  then  performed. 

Gastro-enterostomy  may  be  quickly  performed  by  the 
use  of  a  large-sized  Murphy  button.  Murphy  says  that 
in  some  reported  cases  the  button  has  slipped  back  into 
the  stomach,  but  this  accident  can  be  prevented  by  the 
use  of  an  oblong  button  and  by  making  the  anastomosis  on 
the  posterior  stomach-wall.  The  same  surgeon  advises  us  to 
scarify  the  peritoneum  to  hasten  union,  and  says  supporting 
sutures  about  the  button  are  not  required,  except  when 
considerable  tension  exists.  There  is  no  question  that  an 
anastomosis  on  the  anterior  wall,  accomplished  by  a  Murphy 
button,  can  be  speedily  performed.  Anastomosis  on  the 
posterior  wall  cannot  be  performed  speedily,  and  it  sacrifices 
the  great  advantage  of  the  button  operation — that  is,  speed. 
53 


834      DISEASES  AND   INJURIES   OE   THE  ABDOMEN. 

In  Spite  of  the  reported  cases,  we  can  truthfully  assert  that 
the  danger  of  the  iDutton  producing  grave  trouble  is  slight. 

Gastrogastrostomy  is  an  operation  performed  for  hour- 
glass contraction  of  the  stomach,  a  condition  which  occasion- 
ally ensues  on  the  healing  of  an  ulcer.  In  this  operation  an 
anastomosis  is  effected  between  the  pyloric  and  cardiac  ends. 
Wolfe,  Watson,  Wolfler,  and  Eiselberg  have  performed  this 
operation.  Weir  and  Foote  maintain  that  double  gastro- 
enterostomy, "tapping  each  sac,"  is  a  preferable  proced- 
ure.' In  some  cases  an  operation  identical  with  pyloro- 
plasty can  be  performed  (incision  of  the  constriction  in  the 
direction  of  the  long  axis  of  the  stomach  and  suturing  verti- 
cally). 

Gastroplication  (Brandt's  Operation  of  Stomach- 
reefing  for  Dilated  Stomach). — Apply  sutures  in  the 
anterior  wall  so  as  to  form  reefs,  then  tear  through  the  great 
omentum  and  apply  sutures  in  the  posterior  wall.  The 
sutures  pass  through  the  serous  and  muscular  coats.  A 
continuous  suture  may  be  used  on  the  anterior  wall  and 
another  on  the  posterior  wall,  or  numerous  interrupted 
sutures  may  be  inserted.  This  operation  is  of  questionable 
value,  and  must  never  be  used  if  stenosis  of  the  pylorus 
exists,  and  stenosis  of  the  pylorus  is  the  most  common  cause 
of  gastric  dilatation. 

Gastropexy  (Buret's  Operation). — It  has  been  shown 
by  Duret  that  dyspepsia  of  a  peculiarly  severe  type  may  be 
produced  by  prolapse  or  downward  displacement  of  the 
stomach.  In  this  condition  he  advises  the  following  opera- 
tion :  perform  a  median  laparotomy,  but  do  not  incise  the 
peritoneum  in  the  upper  portion  of  the  Avound.  Expose  the 
stomach  and  fix  it  by  means  of  a  silk  suture  to  the  undivided 
but  exposed  peritoneum.  The  suture  should  be  parallel  to 
the  lesser  curvature  and  near  the  pylorus  should  be 
horizontal." 

Duodenostomy  and  Jejunostomy. — It  has  been  sug- 
gested that  one  of  the  above  operations  should  be  performed 
in  cases  of  pyloric  obstruction  in  which  pylorectomy  is  not 
feasible. 

Jacobson  disapproves  of  both  procedures,  and  objects 
particularly  to  duodenostomy,  because  it  involves  a  fixed 
portion  of  the  intestine  which  is  difficult  to  deal  with,  and 
because  important  fluids  escape  constantly  from  the  fistula.^ 

^  F.  S.  Watson,  in  Bostoji  JlLd.  atid  Surg.  Jour.,  April  2,  1S96;  Weir  and 
Foote,  Medical  N'civs,  April  25,  1S96. 

*  Rev.  de  Chir.,  June,  1896.  ^  Jacobson's  Operations  of  Surgery. 


ENTE  RECTO  MY. 


835 


The  same  author  objects  to  jejunostomy  because  of  the 
inevitable  leakage  of  nutritiv^e  fluids. 

Reported  cases  of  jejunostomy  do  not  indicate  that  the 
operation  prolongs  life  to  any  considerable  degree. 

Bnterectomy,  or  Resection  of  the  Intestine  with 
Approximation  by  Circular  Bnterorrhaphy. — After 
opening  the  abdomen  isolate  the  loop  of  intestine  it  is  intended 
to  resect.  Push  a  rubber  tube  through  the  mesenter}'  close  to 
the  bowel,  above  the  seat  of  operation,  and  pass  a  rubber  tube 
through  the  mesentery  below  the  seat  of  operation.  Empty 
this  segment  of  bowel  by  squeezing  and  stroking,  tighten  the 
rubber  tubes,  and  clamp  them  to  keep  the  bowel  empty 
(Fig.  294).  Instead  of  tubes,  strips  of  iodoform  gauze  may 
be  used  to  encircle  the  bowel.  The  diseased  intestine  is 
resected,  each  incision  being  carried  through  a  healthy  seg- 
ment. The  lumen  of  each  end  of  the  divided  gut  is  irrigated 
with  salt  solution.  The  divided  surfaces  are  approximated 
by  a  double  row  of  sutures — a  continuous  suture  for  the 
mucous  membrane,  and  Lembert's,  Dupuytren's,  or  Cushing's 
suture  to  effect  inversion.  Thoroughly  satisfactor}'  approxi- 
mation can  be  effected  by  one  row  of  Halsted  sutures.  If  a 
redundant  fold  of  mesenter}'  is  left,  it  can  be  stitched  at  its  raw 
edge  (Fig.  295).  Many  surgeons  remove  a  V-shaped  piece 
of  mesentery  and  tie  the  divided  mesenteric  vessels  (Fig.  294). 
The  tubes  are  removed,  and  the  wound  is  cleansed,  closed, 
and  dressed. 


Fig.    294. — Excision   of  bowel  :  first  step 
(Esraarch  and  Kowalzig). 


Fig.  295. — Excision  of  bov.  e!  w  ith  en- 
terorrhaphy  and  stitching  of  the  redun- 
dant mesentery:  second  ^tep  (Esmarch 
and  Kowalzig). 


Senn  effects  invagination  by  means  of  a  bone  ring  (Fig.  297). 

If  the  two  segments  of  bowel  are  unequal  in  size,  the  nar- 
row part  of  the  bowel  should  be  cut  obliquely  and  the 
larger  part  should  be  cut  transversely.     To  meet  this  com- 


836      DISEASES  AND   INJURIES   OF  THE  ABDOMEN. 

plication  Billroth  devised  lateral  implantation.  Suppose  the 
cecum  has  been  resected :  its  lower  end  is  closed  by  Lembert 
sutures,  an  opening  is  made  in  the  long  axis  of  the  periphery 
of  the  colon  opposite  the  attachment  of  the  mesocolon,  and 
the  end  of  the  ileum  is  sutured  into  this  incision. 


Fig.  296. — Resection  of  intestine  ;  a.  b,  the  tw  -  Lu. -_-  t  the  button;  c,  the  two  portions 
clamped  together;  d,  introduction  of  the  sutures  for  holding  each  half  of  the  button  in  place. 
The  lower  figure  shows  the  conapleted  union  of  the  intestine  by  the  Murphy  button;  the  slip 
in  the  mesentery  has  been  closed  by  linear  union  (after  Zuckerkandl;. 

Senn  advises  the  insertion  of  an  anastomosis-ring  in  the 
ileum,  the  invagination  of  the  colon  as  the  ring  is  pulled  into 
place,  and  firm  suturing  of  the  line  of  junction.  By  Senn's 
method  the  ileum  may  be  implanted  into  the  end  of  the  colon  or 
into  a  slit  in  the  wall  of  the  large  bowel  after  the  end  of  the  colon 
has  been  closed.     In  some  cases,  where  one  portion  of  bowel 


ENTERECTOMY. 


837 


is  larger  than  the  other,  lateral  anastomosis  is  the  prefer- 
able method.  For  a  full  week  after  an  intestinal  resection 
the  patient  is  fed  chiefly  by  nutrient  enemata.  During  the 
first  twenty-four  hours  nothing  is  given  by  the  stomach  but 
bits  of  ice,  and  for  the  next  six  days  but  a  very  little  liquid 
food  is  allowed  to  be  swallowed. 

The  use  of  Murphy's  button  permits  of  rapid  approximation 
after  resection  (Fig.  296,  c).  This  button  closely  approximates 
the  portions  of  the  intestine  within  its  bite,  rapid  adhesion 
taking  place.  The  diaphragm  of  tissue  undergoes  pressure- 
atrophy,  and  liberates  the  button,  which  is  passed  per  anum. 
It  is  claimed  that  the  button-opening  contracts  but  slightly. 
For    end-to-end  or    side-to-side  approximation  of  the  small 


Fig.  297. — Senn's  modification  of  Jobert's  invagination  method  ;  A,  upper  end  lined 
with  ring  ;  B,  invagination  sutures  in  place  ;    C,    lower  end. 


intestine  a  No.  3  button  is  used.  For  similar  operations  on 
the  large  intestine  a  No.  4  button  is  employed  (Murphy). 
After  the  resection  one-half  of  a  button  is  inserted  into  each 
segment,  and  is  held  in  place  by  a  purse-string  suture  of  silk 
which  passes  through  all  the  coats  (Fig.  296).  The  redun- 
dant mucous  membrane  is  tucked  in  or  clipped  off,  so  that  it 
will  not  be  interposed  between  the  serous  surfaces.  The  serous 
surfaces  are  scratched  with  a  needle  and  the  halves  of  the 
button  are  locked  (Fig.  296).  It  is  not  necessary  to  surround 
the  margin  of  junction  with  sutures.  Murphy  says  that  liquid 
nourishment  should  be  given  as  soon  as  the  patient  has  recov- 
ered from  the  effect  of  the  ether,  and  that  the  bowels  should 
be  moved  at  an  early  period,  and  frequent  evacuations  should 
be  maintained.  If  the  button  does  not  pass  in  four  weeks, 
examine  the  rectum  for  it.^     The  situation  of  the  button  can 

1  John  B.   Murphy,  iu  Med.  Nezi'S,  Feb.  9,  1S95. 


838      DISEASES  AND   INJURIES   OF  THE  ABDOMEN. 

be  ascertained  by  the  ,r-rays.  After  intestinal  resection 
Halsted  performs  circular  enterorrhaphy  by  means  of  his 
mattress-sutures. 

Maunsell  has  devised  a  most  ingenious  method  of  cir- 
cular enterorrhaphy.  The  two  portions  of  bowel  are  at- 
tached by  two  fixation-sutures  which  penetrate  all  the 
coats  (Fig.  298).  An  incision  one  and  one-half  inches  in 
length    is    made    through    the    wall    of  the    proximal    seg- 


FlG.    2Q 


-Maunsell's  method  of  anastomosis  (after  Wiggin). 


ment  of  gut,  about  one  inch  from  its  edge.  The  fixa- 
tion-sutures are  brought  through  this  opening,  traction  is 
made  upon  them,  the  distal  portion  of  the  bowel  is  in- 
vaginated  into  the  proximal  portion,  and  the  ends  emerge 
from  the  opening,  their  peritoneal  surfaces  being  in  contact 
(Fig.  298).  Sutures  of  silk  are  passed  through  both  sides 
of  the  area  of  invagination,  the  threads  are  caught  up  in  the 
center,  cut,  and  tied  on  each  side.     The  fixation-sutures  are 


ENTE  RECTO  MY. 


839 


cut  off.     The  invagination  is  reduced  by  traction.    The  longi- 
tudinal cut  is  closed  by  Lembert  sutures. 

Mayo    Robson    performs    circular  enterorrhaphy    over    a 
bobbin   of  decalcified  bone  (Fig.   299).     Allingham   uses  a 


Fig.  299. — Robson's  decalcified  bone  bobbin. 


bone  bobbin  the  shape  of  two  cones  joined  at  their  apices. 
The  bobbin  is  decalcified  except  an  area  at  the  center 
(Fig.  300).  Kocher  performs  circular  enterorrhaphy  as 
follows  :  a  fixation-suture  is  introduced  through  the  bowel 
at  the  mesenteric  attachment  and  another  is  inserted  at  an 


Fig.  300. — AUingham's  decalcified  bone  bobbin. 


opposite  point.  The  intestinal  ends  are  approximated  by 
a  continuous  silk  suture,  which  passes  through  all  of  the 
coats,  but  which  includes  more  of  the  serous  than  of  the 
mucous  coat.  The  suture-line  is  overlaid  by  a  continuous 
Lembert  suture  which  includes  the  serous  and  a  portion  of 
the  muscular  coat.  Harris  removes  a  portion  of  mucous 
membrane  from  the  distal  end  by  means  of  a  curet.  Three 
needles  are  threaded  with  fine  silk.  The  first  needle  is 
pushed  through  the  bowel-wall  to  one  side  of  the  mesentery. 
The  point  of  the  needle  picks  up  a  portion  of  the  distal  end 
transversely.  The  needle  is  used  as  a  lever  to  invaginate  the 
distal  end  into  the  proximal  end.  The  same  procedure  is 
carried  out  with  the  other  needles.  When  invagination  is 
effected  the  needles  are  pulled  through  and  the  threads  are 
tied.     The  free  end  of  the  bowel  is  now  sutured  to  the  in- 


840      DISEASES  AND   INJURIES    OF   THE   ABDOMEN. 

vaginated    part   by   interrupted    inversion    sutures    or  by  a 
continuous  inversion  suture  broken  once  (Fig.  301).^ 

Some  surgeons  employ  inflatable  rubber  cylinders  in 
making  an  end-to-end  anastomosis  (Halsted,  Downes,  and 
others).  The  method  was  devised  by  Treves,  but  was  subse- 
quently abandoned  by  him.  Halsted  maintains  that  the  use 
of  the  inflatable  rubber  cylinder  enables  the  surgeon  to  fin- 
ish the  operation  more  quickly  and  to  dispense  with  clamps ; 
arrests  the  vermicular  motion  of  the  intestine ;  makes  easy 
the  adjustment  of  two  pieces  of  intestine  of  unequal  size; 


Fig.  301. — Harris's  method  of  circular  enterorrhaphy. 

and  renders  it  possible  to  apply  stitches  rapidly,  evenly,  and 
securely.^  Three  presection  sutures  are  inserted ;  a  portion 
of  bowel  and  a  V-shaped  piece  of  mesentery  are  resected, 
the  mesenteric  incision  being  so  made  as  to  leave  a  ves.sel 
uncut  at  each  edge  to  supply  each  end  of  the  divided  intes- 
tine. The  mesenteric  vessels  are  ligated  and  the  ends  of 
the  bowel  are  pulled  together  by  the  presection  stitches,  two 
of  which  are  tied.  The  collapsed  rubber  cylinder  is  pushed 
into  the  bowel  by  means  of  forceps  and  is  inflated  with  a  syringe 

'  Chicago  Med.  Record,  Jan.,  1897.  '  Phila.  Med.  Jour.,  Jan.  8,  1898. 


EXTERECTOMY. 


841 


(Fig.  302).  Twelve  mattress-sutures  are  inserted,  the  bag 
is  collapsed  and  withdrawn  and  the  sutures  are  tied,  the  stitch 
a  being  tied  first  (Fig.  302).     The  slit  in  the  mesenter>-  is 


Fig.  :!02.— Use  of  Halsted's  inflated  rubber  cylinder  in  circular  enterorrhaphy. 


sewed  in  such  a  way  that  the  mesenteric  vessels  which  nour- 
ish the  bowel  are  not  interfered  with  (Fig.  303). 

Laplace  has  devised  forceps  which  greatly  facilitate  sutur- 


■ymiEiF 


'i1'%i\W)^J;pi| 


Fig.  30^. — Suture  of  the  mesentery  after  circular  enterorrhaphy  ^Halsted). 

ing,  which  make  it  eas}'  to  obtain  an  even  suture-line,  and 
which  can  be  withdrawn  after  the  suturing  is  finished,  the 
small  opening  through  which  the  instrument  emerged  being 
closed  with  a  stitch  (Figs.  304.  305).     By  aid  of  Laplace's 


842      DISEASES  AND   INJURIES   OF   THE  ABDOMEN. 

forceps  the   operation  can  be  neatly  and  rapidly  performed, 
but   a    large    diaphragm    is    formed,  a  considerable    area   is 


Fig.  304.— Laplace's  forceps  for  intestinal  anastomosis. 

exposed  to  infection,  the  tissues  of  the  diaphragm  are  bruised 
and  may  slough,  and  it  seems  probable  that  considerable  con- 


Fig.  305. — End-to-end  anastomosis  with  the  aid  of  Laplace's  forceps. 

traction  will  follow.     Another  objection  is  that  an  infected 


LATERAL    INTESTINAL    ANASTOMOSIS. 


843 


instrument  is  withdrawn  from  the  bowel  and  may  con- 
taminate the  peritoneum. 

I^ateral  Intestinal  Anastomosis.  —  Approximation 
may  be  effected  b\-  other  methods  than  by  end-to-end  junc- 
tion or  implantation.  Lateral  anastomosis  may  be  prac- 
tised after  intestinal  resection  or  may  be  done  with  prelimi- 
nary resection  for  the  purpose  of  short-circuiting  the  fecal 
current  to  avoid  an  obstruction. 

Operation  -with  Rings. — In  this  operation  a  portion  of 
bowel  above  the  obstruction  and  a  loop  below  the  obstruc- 


'^,>^^  .V 


Fig.  306. — Senn's  entero-anastomosis :    A,  Senn's  bone  plate  ;    b,  intestinal  anastomosis ; 
C,  operation  complete. 


segments    are 

around    them 

are  needed  for 


tion  are  brought  into  the  wound.  These 
emptied,  and  are  kept  empt}'  by  fastening 
rubber  tubes  or  iodoform  strips.  Two  tubes 
each  loop  of  bowel.  Pack  in 
gauze  pads.  Make  an  in- 
cision in  one  loop,  in  the 
long  axis  of  the  bowel,  on 
the  surface  awa}"  from  the 
mesenter}^ ;  permit  the  con- 
tents to  escape  externalh' ; 
irrigate  this  segment  with 
saline  solution ;  and  introduce 
the  bone  plate  of  Senn  ( Fig. 
306,-  a)  or  Abbe's  catgut  ring. 
Calyx-eyed  needles  are  used, 
and  the  threads  of  the  ring 
are  carried  through  the  coats 
of  the  bowel  and  are  gath- 
ered together  in  the  bite  of 
a  pair  of  forceps.  The  other 
loop  of  intestine  is  treated 
in  a  similar  manner.  The 
intestines     are    so    brought 

together  that  the  two  wounds  are  opposite  each  other,  the 
posterior  sutures  being  tied  first,  the   upper  next,  then  the 


Fig. 


Afethod  of  passing  the  silk  sutures 
nserting  the  rings  of  Abbe. 


844      DISEASES  AND   INJURIES   OF   THE  ABDOMEN. 

lower,  and  finally  the  anterior  threads.  The  ends  of  the  threads 
are  cutoff  and  the  entire  anastomosis  is  surrounded  by  a  layer 
of  Lembert  or  Halsted  sutures  or  is  encircled  by  Cushing's 
suture.  Fig.  306,  B,  shows  an  intestinal  anastomosis  partly 
finished,  and  Fig.   306,  c,  shows  an  anastomosis  complete. 


Fig.  308. — ! 


■Showing  relative  size  of  incision  and  method  of  introducing  sutures  in  lateral 
approximation  with  Murphy's  button. 


Fio-.  307  shows  the  passing  of  the  sutures  when  the  catgut 
rings  of  Abbe  are  employed.  After  an  intestinal  resection, 
each  end  can  be  closed  and  anastomosis  effected  as  described 
above.      Lateral  anastomosis   can   be    accomplished  with  a 


^^paTvrV^^ 


Fig.  309. — Suturing  intestines  in  apposition  before  incision  (Abbe). 

Murphy  button,  the  intestine  being  prepared  for  the  button 
as  is  shown  in  Fig.  308. 

Abbe's  method  of  anastomosis  without  mechanical  aid 
is  as  follows :  after  resecting  the  bowel  and  mesentery 
and  closing  the  ends  of  the  bowel  he  places  the  extremi- 
ties  side  by  side    and    applies    two   rows    of  a    Dupuytren 


LATERAL    LXTESTLNAL   AXASTOMOSIS. 


845 


suture,    one-quarter    of    an    inch    apart.       These    rows    of 
sutures   are   an    inch    longer   than   the    sHt    in    the    bowel 


Fig.  -10.— Showing-  the  four-inch  incision  and  sewing  of  the  edges  (Abbe). 

will  be    (Fig.    309),    the    thread    at    the    end    of    each    row 
being  left  fong.      An  incision  is  made  in   the  bowel,  one- 


F:g   ^ii  — Halsted's  operation  for  lateral  anastomosis,  showing  four  steps  of  same  (Jessett, 
"  ^  from  Halsted). 

quarter  of  an  inch  from  the  sutures,  both  rows  of  threads 
beincT  on  the  same  side  of  the  cut  This  incision  is  four 
inches  long.     The  other  portion  of  bowel  is  then  incised  in 


846      DISEASES  AND   INJURIES   OF   THE  ABDOMEN. 

the  same  way.  The  adjacent  cut-edges  are  united  by  a 
whip-stitch  which  goes  through  all  the  coats,  and  the  free 
cut-edges  are  stitched  in  the  same  manner  (Fig.  310).  The 
surgeon  now  utilizes  the  long  threads  of  the  first  sutures, 
and  brings  the  serous  surfaces  of  the  opposite  sides  together 
by  means  of  Dupuytren's  suture.  Halsted  performs  anasto- 
mosis as  follows  :  he  places  the  two  portions  of  bowel  with 
their  mesenteric  borders  in  contact.  Six  quilted  sutures  of 
silk  are  introduced,  tied,  and  cut  off  (Fig.  311,  a).  At  each 
end  of  this  row  of  sutures  two  quilted  sutures  are  intro- 
duced, tied,  and  cut  (Fig.  311,  Z-).  A  number  of  quilted 
sutures  are  introduced,  as  is  shown  in  Fig.  311,  c.  The  intes- 
tinal openings  are  made  with  scissors,  and  the  sutures  last 
introduced  are  tied  and  cut  off  (Fig.  311,  d^. 

J.  Shelton  Horsley  has  suggested  an  ingenious  method  of 
intestinal  anastomosis  which  secures  for  the  sutured  portion 
a  greater  diameter  than  that  normal  to  the  intestine.^  After 
resection  of  the  intestine  and  a  V-shaped  piece  of  mesentery, 
the  ends  of  the  bowel  are  placed  side  by  side,  the  openings 
being  in  the  same  direction,  and  are  clamped  in  place  (Fig. 
312).     The  first  stitch  approximates   the  two   limbs  of  the 


Fig.  312. — Represents  the  ends  of  the  intestine  in  position  and  grasped  by  the  artery-for- 
ceps. The  first  row  of  sutures  has  been  partially  applied,  the  septum  partly  cut  away,  and 
the  second  row  of  overhand  sutures  begun,  a,  b,  are  the  two  ends  of  the  intestine  ;  c,  c,  the 
first  row  of  sutures  (Gushing);  </,  the  second  row  of  sutures  (overhand);  f,  the  septum  ; 
y  and  g,  the  mesentery  (J.  Shelton  Horsley). 


bowel  near  the  mesenteric  attachment,  is  carried  obliquely 
for  about  two  inches  to  the  border  opposite  the  mesenteric 
attachment,  and  continued  over  the  other  side  (Fig.  312). 
The  septum  is  cut  away,  a  margin  being  left  one-third  of  an 

'  A^eui   York  Polycii7iic. 


LA  TERAL    INTESTINAL    ANASTOMOSIS. 


847 


inch  wide.     The  edge  of  the  shelf  made  by  cutting  the  sep- 
tum is  sutured.     When  the  suture   reaches  the  end  of  the 


Fig.  313. — Operation  nearly  completed.  The  septum  has  been  cut  away,  and  the  row  of 
overhand  sutures  has  been  brought  almost  to  its  point  of  commencement.  The  cut  also  shows 
the  first  row  of  sutures  (Gushing)  as  it  should  be  continued  after  the  overhand  sutures  are 
finished  (J.  Shelton  Horsley). 

shelf  it  is  continued  by  invaginating  the  rest  of  the  resected 
ends  (Fig.  313). 

Bodine's  method  of  intestinal  anastomosis  is  referred  to  on 
page    851.     Laplace   of  Philadelphia   has    devised    an  oper- 


FiG.  314. — Lateral  anastomosis  with  the  aid  of  Laplace's  forceps. 

ation  in  which  temporar}^  approximation  is  effected  by  means 
of  forceps,  the  instrument  being  withdrawn  before  the  abdo- 


848      DISEASES  AND   INJURIES   OF   THE   ABDOMEN. 

men  is  closed.  Junction  of  two  segments  of  intestine  can  be 
quickly  and  neatly  effected  by  this  method  and  the  suture 
line  is  even  and  secure.  The  objections  are  that  an  infected 
instrument  is  withdrawn  from  the  bowel  and  may  contamin- 
ate the  surface — that  a  large  septum  is  formed  and  tightly 
squeezed  and  this  septum  may  slough,  or  may  become  in- 
fected conditions  which  will  be  followed  by  infection  of  the 
suture  line,  and  that  contraction  of  the  collar  may  ensue. 
Figs.  314,  315  illustrate  the  use  of  Laplace's  forceps  in 
lateral  anastomosis. 


Fig.  315. — Withdrawal  of  Laplace's  forceps. 

Consideration  of  Methods  of  Intestinal  Approxima- 
tion.— The  best  method  of  uniting  a  divided  intestine  is  a 
matter  of  dispute.  The  Murphy  button  can  be  applied  with 
great  rapidity,  and  rapid  operation  is  of  immense  importance 
in  intestinal  work.  The  opening  left  by  the  Murphy  button  is 
small  (too  small  some  surgeons  think),  but  it  does  not  strongly 
tend  in  most  instances  to  contract  because  the  tissue-dia- 
phragm is  separated  by  tissue-atrophy  and  not  by  inflamma- 
tory gangrene.  Occasionally  the  opening  made  by  the  but- 
ton contracts  and  gives  trouble  ;  occasionally  the  lumen  of  the 
button  blocks  with  feces  ;  occasionally  the  button  is  retained, 
this  latter  complication  being  especially  frequent  after  anterior 
gastro-enterostomy.  If  the  button  is  used,  liquid  food  should 
be  given  soon  after  the  effect  of  the  anesthetic  has  passed  off, 
and  movement  of  the  bowels  should  be  obtained  at  an  early 


OPE  RATIO  X  FOR   INTUSSUSCEPTION.  849 

period  after  operation  and  frequent  evacuations  should  be 
maintained.  The  button  gives  better  results  in  end-to-end 
approximation  than  in  lateral  anastomosis.  Laplace's  forceps, 
the  decalcified  bone  plates  of  Senn,  the  catgut  rings  of  Abbe, 
the  catgut  strands  inside  of  rubber  tubing  of  Brokaw, 
Chaput's  button,  Allingham's  bone  bobbin,  Robson's  bone 
bobbin,  Clark's  bobbin.  Miller's  bone  buttons,  buttons  of 
leather,  potato,  and  carrot,  all  have  their  adherents.  Of 
mechanical  appliances  the  best  are  Murphy's  button,  the 
bone  ring,  Laplace's  forceps,  and  the  inflatable  rubber  cylinder. 
Of  recent  years  many  surgeons  have  abandoned  all  mechan- 
ical aids,  and  have  returned  to  closure  without  any  mechanical 
device  whatever.  The  ideal  operation  is  without  these  con- 
tri\-ances.  But  such  devices  are  time-savers,  and  to  lessen 
the  time  of  operation  will  often  save  life.  What  method  to 
follow  must  be  determined  in  each  particular  case  by  a  study 
of  the  necessities  of  the  situation.  Nevertheless  it  may  be 
possible  to  formulate  a  few  general  rules.  If  the  condition  of 
the  patient  is  excellent  and  the  bowel  is  in  a  fairly  healthy  con- 
dition well  above  and  well  below  the  seat  of  trouble,  end-to- 
end  approximation  should  be  performed  by  simple  circul-ar 
enterorrhaphy.  If  the  condition  of  the  patient  is  such  as 
to  make  haste  necessary,  use  a  Murphy  button.  If  the  bowel 
below  the  seat  of  trouble  is  much  contracted,  do  not  use  a 
Murphy  button,  but  use  Senn's  bone  plate,  or  Robson's  bob- 
bin, or,  better  still,  do  simple  enterorrhaphy.  If  the  surgeon 
is  obliged  to  join  a  very  much  distended  bowel  to  a  very 
much  contracted  bowel,  perform  end-to-side  approximation 
(implantation)  with  the  bone  plate  of  Senn,  by  simple  sutur- 
ing, or  else  effect  side-to-side  junction  by  the  method  of 
Abbe.^ 

Operation  for  Intussusception. — If  hydrostatic  press- 
ure or  air  distention  fails  to  relieve  the  condition,  operation 
should  be  performed.  The  abdomen  is  opened,  and  the 
surgeon  endeavors  by  manipulation  to  reduce  the  intussus- 
ception by  pushing  it  back,  not  by  pulling  it  out.  If 
the  intussusception  is  gangrenous,  perform  intestinal  resec- 
tion and  circular  enterorrhaphy.  The  same  rule  main- 
tains when  malignant  disease  of  the  gut  exists  (D'iVrcy 
Power).  It  is  inadvisable  to  make  an  artificial  anus.  Maun- 
sell's  operation  is  suited  to  cases  of  irreducible  intussuscep- 
tion. It  is  performed  as  follows  :  a  longitudinal  incision  is 
made  in  the  intussuscipiens.     The  intussusception  is   gently 

"^  See  the  discussion  of  this  subject  by  the  late  Greig  Smith  in  his  Abdovthial 
Surgery. 

54 


850      DISEASES  AND    INJURIES    OF   THE   ABDOMEN. 

pulled  upon  and  is  caused  to  protrude  from  this  opening. 
Two  straight  needles  threaded  with  horse-hair  are  passed  so 
as  to  transfix  the  base,  and  one-fourth  of  an  inch  above  the 
needles  the  intussusception  is  cut  off  The  needles  are 
carried  completely  through,  the  sutures  are  hooked  up  in 
the  middle  and  cut,  and  the  two  ends  are  tied  on  each  side. 
These  sutures  unite  the  intussusception  to  the  intussuscipiens. 
The  two  surfaces  are  now  carefully  approximated  by  sutures. 
The  sutures  are  cut.  The  stump  is  replaced.  The  longi- 
tudinal incision  is  closed  with  Lembert  sutures.^ 

Senn's  Operation  for  Fecal  Fistula. — Suture  the 
opening  transversel}-  with  Czerny  sutures  of  silk  in  order 
to  prevent  infection.  Cleanse  the  surface  thoroughly.  Open 
the  abdomen  and  separate  the  edges  of  the  bowel  from  the 
parietes.  Deliver  the  portion  of  bowel  which  contains  the 
fistula  and  apply  Lembert  sutures  over  the  Czerny  sutures. 
Another  method  is  to  open  the  abdomen  above  the  fistula, 
insert  the  fingers,  cut  out  the  skin  and  tissues  around  the 
fistula  in  an  elliptical  course,  leaving  them  attached  to  the 
bowel,  draw  the  bowel  from  the  abdomen,  pack  gauze  around, 
remove  the  tissues  adherent  to  it,  and  suture  the  fistula 
transversely  (Hearn). 

Enterostomy  is  the  making  of  an  artificial  anus.  If  per- 
formed in  the  large  bowel,  it  is  called  colostomy.  In  some 
cases  of  intestinal  obstruction  it  is  necessary  to  open  the 
small  intestine,  and  if  this  is  required  the  artificial  anus  should 
be  made  as  near  as  possible  to  the  cecum.  The  nearer 
the  stomach  it  is  made  the  more  apt  is  the  patient  to  die  of 
lack  of  nourishment.  The  anus  may  be  made  in  the 
middle  line  or  in  the  right  iliac  region.  The  bowel  is 
fixed  and  opened  as  directed  under  colostomy.  In  acute 
intestinal  obstruction  it  may  be  necessary  to  open  the 
bowel  at  once.  In  such  a  case  Paul's  tube  is  very  useful. 
Paul's  tube  is  made  of  glass,  is  bent  to  a  right  angle,  and  has 
a  rim  near  each  end.  The  large  tube  is  used  in  the  colon,  the 
small  tube  in  the  small  intestine.  A  small  opening  is  made 
in  the  intestine,  the  tube  is  introduced,  and  is  tied  in  place  by 
a  silk  suture  which  surrounds  all  of  the  coats  of  the  bowel,  a 
quantity  of  feces  is  caught  in  a  basin,  a  rubber  tube  is  fastened 
to  the  glass  tube,  and  fluid  feces  are  collected  in  a  bottle 
under  antiseptic  fluid."  In  from  three  or  four  days  to  a  week 
the  tube  becomes  loose  and  can  be  removed. 

Inguinal    Colostomy. — Maydl's    Operation. — In    this 

1  T.  Pickering  Pick,  Quarterly  Med.  Jour.,  Jan.,  1897. 
*  Paul,  in  Liverpool  iMed.-C/iir.  Jour.,]\i\y,  1892. 


IXGCIXAL    COLOSTOMY. 


851 


operation  a  vertical  or  oblique  incision  four  inches  long  is  made 
over  the  portion  of  colon  to  be  incised.  In  all  cases  where  it 
is  possible,  do  a  left  inguinal  colostom\-.  The  colon  usually 
bulges  into  the  wound,  but  if  it  does  not  it  ma\-  easily  be  found 
by  following  with  the  finger  the  parietal  peritoneum  outward, 
backward,  and  inward,  the  first  obstruction  it  encounters 
being  the  mesocolon.  Draw  the  colon  out  of  the  wound 
until  its  mesenteric  attachmeiit  is  level  with  the  abdominal 
incision.  Push  a  glass  bar  through  a  slit  in  the  mesocolon 
near  the  bowel,  and  wrap  the  ends  of  the  bar  with  iodoform 
gauze  to  prevent  slipping.  Instead  of  the  bar,  a  piece  of 
gauze  can  be  employed,  or  a  bridge  of  skin  can  be  made 
under  the  bowel  by  suturing  the  two  skin  edges.  The  two 
parts  of  the  flexure  are  stitched  together  by  sutures  w^hich 
penetrate  to  and  catch  the  submucous  coat  (Fig.  316).     If  it  is 


Fig.  316. — Inguinal  colostomy  (after  Zuckerkandl). 

necessar}^  to  open  the  colon  during  the  operation,  stitch  the 
serous  coat  of  the  bowel  to  the  parietal  peritoneum  before 
opening.  Whenever  possible,  wait  from  twelve  to  twenty-four 
hours  before  opening.  The  colon  is  opened  by  the  cauter}'  or 
by  scissors.  If  the  artificial  anus  is  to  be  permanent,  make  a 
transverse  incision  through  the  bowel.  Some  surgeons  cut 
one-fourth  way  through  the  colon  when  it  is  first  opened, 
and  entirely  across  at  a  later  period.  If  the  artificial  anus 
is  to  be  temporar}',  the  incision  is  longitudinal.  This  oper- 
ation has  great  adxantages  :  it  is  quick,  certain,  reasonably 
safe,  and  satisfactorily  prevents  fecal  accumulation  below  the 
opening. 

Bodine's  Operation. — Bodine's  method  of  colostom\'  per- 
mits of  a  future  restoration  of  the  fecal  current  by  an  easil\-  per- 
formed anastomosis.     This  surgeon  maintains  that  the  spur 


852      DISEASES  AND   INJURIES   OE   THE  ABDOMEN 


Fig.  317. — Bodine's  method  of  colostomy,  showing  one  side  of  the  loop  after  it  has  been 
sutured,  passed  back  into  the  cavity  and  stitched  into  the  abdominal  wound.  The  lesion  is 
left  protruding,  and  the  dotted  line  indicates  where  the  protrusion  is  to  be  clipped  off. 

after  colostomy  should  reach  to  and  remain  at  the  level  of 
the  skin,  a  condition  impossible  of  attainment  by  hanging 
the  bowel  over  a  rod  or  piece  of  gauze,  because  a  spur  thus 


Fig.  318. — Bodine's  method  of  colostomy,  showing  the  septum  to  be  divided  in  restoring 
the  fecal  current ;  Grant's  clamp  in  position  for  the  division.  (In  permanent  colostomy  this 
septum  remains  as  a  rigid  and  effective  spur). 


CHOLECYSTOTOMY.  853 

formed  is  not  thick  and  rigid  and  is  inevitabl}^  dragged  below 
tlie  skin-level,  and  when  this  dragging  has  taken  place  some 
fecal  matter  will  pass  into  the  bowel  below  the  artificial  anus. 
Bodine  opens  the  abdomen,  sutures  the  parietal  peritoneum 
to  the  skin,  seeks  for  the  lesion,  and  draws  it  with  six  inches 
of  healthy  bowel  out  of  the  incision.  He  lays  the  limbs  of 
the  loop  side  by  side.  He  inserts  a  silk  stitch,  beginning  at 
the  point  where  exsection  is  to  be  made,  and  for  six  inches 
unites  the  two  segments  close  to  their  mesenteric  borders. 
The  loop  is  dropped  into  the  abdomen  until  the  beginning 
of  the  suture  is  on  a  level  with  the  skin,  and  at  this  point  it 
is  fastened  to  the  abdominal  wound  with  a  continuous  catgut 
suture.  The  protruding  lesion  is  cut  off  along  the  dotted 
line  (Fig.  317).  The  artificial  anus  is  thus  established.  When 
it  is  desired  to  close  the  artificial  anus,  di\'ide  the  septum  with 
scissors  or  a  Grant  clamp,  and  close  the  abdominal  wound 
(Fig.  318V 

Lumbar  colostomy  is  a  most  unsatisfactory  operation, 
which  does  not  completely  intercept  the  fecal  current,  and 
which  leaves  the  patient  in  a  condition  of  wretched  discom- 
fort.    It  is  rarely  performed  at  the  present  day. 

Cholecystotomy  is  the  operation  of  opening  the  gall- 
bladder in  order  to  remove  gall-stones  or  secure  drainaee. 
It  is  performed  in  cases  of  acute  cholecystitis ;  in  hydrops 
of  the  gall-bladder ;  in  cases  of  gall-stone  in  which  jaundice 
has  lasted  for  four  weeks  or  more,  and  in  colic  of  the  gall- 
bladder with  fever,  the  colic  having  recurred  a  second  or 
third  time  (Carl  Beck).  The  operation  completed  in  one 
stage  is  performed  as  follows :  The  patient  is  placed  recum- 
bent with  a  sand-pillow  under  the  back.  A  vertical  incision 
is  made  in  the  right  linea  semilunaris.  The  peritoneum  is 
opened.  If  the  gall-bladder  is  distended,  it  is  surrounded 
with  pads  and  aspirated,  and  is  then  opened.  Gall-stones  are 
removed  by  forceps,  the  scoop,  or  irrigation.  The  gall-ducts 
are  examined  by  the  fingers  external  to  them,  and  are 
sounded  if  possible.  If  a  stone  is  wedged  in  the  duct,  try 
to  manipulate  it  back  into  the  gall-bladder.  If  this  fails, 
introduce  an  instrument  from  the  gall-bladder  and  break  up 
the  stone  ;  if  this  fails,  open  the  duct,  remove  the  stone,  and 
close  the  incision  in  the  duct  (Mayo  Robson).  Pass  a  rubber 
tube  which  has  no  side  perforations  into  the  gall-bladder,  cut 
it  off  level  with  the  cutaneous  surface,  and  suture  the  gall- 
bladder to  the  abdominal  aponeurosis.  The  drainage-tube 
can   usually  be  dispensed  with  in  from  a  week   to  ten  days. 

1  New  York  Polyclinic,  Feb.  15,  1S97. 


854      DISEASES  AND   INJURIES   OF  THE  ABDOMEN. 

Some  surgeons  have  advocated  immediate  suture  of  the 
gall-bladder  after  removing  a  stone.  This  is  not  advisable, 
because  small  calculi  may  be  in  the  ducts,  and  minute  frag- 
ments of  stone  are  often  left  in  the  bladder,  and  the  drainage 
will  remove  them  and  relieve  the  diseased  condition  of  the  gall- 
ducts  and  bladder.  Further,  the  operation  with  immediate 
suture  is  decidedly  more  dangerous. 

It  is  advised  by  some  that  the  operation  of  cholecystotomy 
be  performed  in  two  stages.  First,  the  bladder  is  exposed 
and  sutured  to  the  parietal  peritoneum.  When  adhesion 
takes  place  the  gall-bladder  can  be  opened  without  risk  of 
infecting  the  general  peritoneal  surface.  Riedel  advocates 
operation  in  two  stages,  and  so  does  Christian  Fenger  in  cer- 
tain cases.  The  fistula  which  is  left  by  cholecystotomy  usu- 
ally closes  spontaneously,  but  may  not.  If  it  does  not  close 
and  the  secretion  is  pure  mucus,  it  is  evident  that  the  cystic 
duct  is  absolutely  blocked  and  cholecystectomy  should  be 
performed. 

If  the  secretion  is  bile  and  the  common  duct  is  not 
obstructed,  separate  the  edges  of  the  gall-bladder  opening 
from  the  parietal  peritoneum,  endeavoring  to  avoid  entering  the 
abdominal  cavity,  and  close  the  fistula  with  Lembert  or  Hal- 
sted  sutures.  If  the  secretion  is  bile  and  the  common  duct 
is  obstructed  permanently,  perform  cholecystenterostomy. 

Cholecystenterostomy  consists  in  making  an  anasto- 
mosis between  the  gall-bladder  and  intestine,  preferably  the 
duodenum.  It  is  employed  in  cases  of  irremovable  obstruc- 
tion of  the  cystic  or  common  duct.  It  can  be  done  most 
rapidly  and  successfully  by  means  of  a  small  Murphy  button. 
Before  the  gall-bladder  is  incised  it  is  aspirated.  The  oper- 
ation is  shown  in  Fig.  319,  and  is  similar  in  performance  to 
intestinal  anastomosis. 

Cholecystectomy  is  the  extirpation  of  the  gall-bladder. 
Its  performance  may  be  demanded  by  the  existence  of  phleg- 
monous inflammation  or  gangrene,  ulceration,  "in  chronic 
cholecystitis  from  gall-stones  where  the  gall-bladder  is 
shrunken,  and  too  small  to  safely  drain,  and  where  the  com- 
mon duct  is  free  from  obstruction  "  (A.  W.  Mayo  Robson),  in 
empyema  with  greatly  damaged  walls,  in  fistula  associated 
with  irremediable  obstruction  of  the  cystic  duct,  the  common 
duct  being  free,  and  in  some  wounds. 

The  peritoneum  which  covers  the  gall-bladder  must  be 
di\'ided  just  below  the  liver,  the  gall-bladder  is  dissected 
from  the  liver  until  the  cystic  duct  is  reached,  the  duct  is 
ligated  with  silk  and  divided,  the  stump  is  touched  with  pure 


Clio  LED  O  Clio  TOM  Y. 


855 


carbolic  acid  and  is  covered  with  a  layer  of  peritoneum  fas- 
tened by  sutures  of  fine  silk. 

Choledochotomy  is  the  operation  of  incising  the  com- 
mon duct  for  the  removal  of  a  stone.  It  is  also  called  chole- 
docho-lithotomy.  A  sand-bag  should  be  placed  under  the 
back.  The  abdominal  incision  must  be  longer  than  that 
employed  for  cholecystotomy.  The  pylorus  and  stomach 
are  drawn  to  the  left,  the  colon  and  omentum  are  drawn 
downward,  and  the  liver  and  ribs  are  lifted  strongly  upward. 


Fig.  319.— Showing  method  of  holding  parts  while  approximating  a  Murphy  button  in 
cholecystenterostomy. 


"  The  operator  should  now,  after  having  separated  adhe- 
sions, have  a  good  view  of  the  common  duct  within  the  free 
border  of  the  lesser  omentum,  and  on  inserting  his  left  index- 
finger  into  the  foramen  of  Winslow,  or  on  grasping  the  duct 
between  the  index-finger  and  thumb,  he  can,  without  diffi- 
culty, bring  the  duct  well  within  reach,  the  concretion  mak- 
ing a' distinct  projection."  ^     A  longitudinal  incision  is  made, 

1  A.  W.  Mayo  Robson's  Treatise  on  Diseases  of  the  Gall-bladder  and  Bile- 
ducts. 


856      DISEASES  AND   INJURIES   OF   THE   ABDOMEN. 

the  stone  is  removed,  and  a  probe  is  introduced  into  the  duct 
to  determine  whether  other  stones  are  present. 

If  possible,  suture  the  incision  in  the  duct.  This  procedure 
is  rendered  easier  by  the  use  of  Halsted's  hammer  which 
draws  the  duct  toward  the  surface  and  keeps  it  under  con- 
trol (Fig.  320). 

Interrupted  sutures  of  fine  silk  are  used.  The  muscular 
and  serous  coats  may  be  included  in  each  suture,  and  over 
this  layer  Lembert  or  Halsted  sutures  are  applied.  A  drain- 
age-tube is  inserted  and  a  piece  of  iodoform  gauze  is  placed 
upon  the  suture  line,  the  other  end  being  brought  out  of  the 


Fig.  320. — Suture  of  duct  over  hammer. 

abdominal  wound.  This  precaution  is  taken  because  leakage 
may  occur.  If  it  is  found  impossible  to  suture  the  wound 
in  the  duct,  carry  a  glass  tube  down  to  the  opening  and  sur- 
round it  with  iodoform  gauze,  or  make  an  incision  into  the 
loin  after  the  plan  of  Rutherford  Morrison,  and  carry  a  tube 
into  the  right  kidney  pouch,  which  is  the  most  dependent 
part  of  the  peritoneal  cavity  when  the  patient  is  recumbent. 

Splenectomy. — This  operation  is  performed  for  wounds 
and  rupture  of  the  spleen,  cysts,  floating  spleen,  and  non- 
leukemic  splenic  hypertrophy.  It  should  not  be  performed 
if  leukemia  exists.  The  incision  is  from  the  anterior  supe- 
rior spine  of  the  ilium  to  the  ribs  (Bryant).     The  peritoneum 


ABDOMIXAL   HERXIA    OR   RUPTURE.  857 

is  opened.  Adhesions  are  divided  between  ligatures.  If  the 
spleen  is  adherent  to  the  pancreas,  it  ma\'  be  necessary  to  re- 
move a  fragment  of  the  last-named  organ  (Esmarch).  Ligate 
the  suspensor}'  ligament  and  cut  it.  Bring  the  spleen  well  out 
of  the  wound.  Surround  it  with  gauze  pads.  Transfix  the 
pedicle  with  stout  silk.  Tie  it  firmly,  leaving  the  ends  of  the 
ligature  long  for  a  time,  and  cut  through  the  pedicle  beyond 
the  ligature.  Ligate  the  vessels  separately  with  catgut.  Cut 
off  the  long  ends  of  the  silk  ligature  and  drop  the  pedicle 
back,  unless  apprehensive  of  bleeding,  when  it  ma\'  be  fast- 
ened to  the  surface.     The  wound  is  closed  without  drainage. 

About  two  weeks  after  the  remo\-al  of  a  normal  spleen 
certain  definite  changes  happen  in  adults  but  not  in  children. 
These  changes  last  for  several  weeks  and  are  manifested  by 
enlargement  of  the  lymph-glands,  tenderness  of  bones,  and 
blood-changes,  loss  of  weight,  weakness,  thirst,  poh-uria,  ab- 
dominal pain,  elevation  of  temperature,  and  rapid  pulse.^ 
Tizzoni  says  that  these  changes  are  not  obvious  in  children, 
because  in  them  compensatory  organs  act  at  once,  whereas 
in  adults  compensatory  organs  act  slowly  and  with  painful 
effort.  Such  symptoms  are  noticed  when  the  spleen  is  re- 
moved because  of  a  wound  or  a  rupture,  and  rarely  after 
removal  of  a  diseased  spleen.  It  is  likely  that  compensating 
organs  become  acti\-e  when  the  spleen  is  diseased,  and  conse- 
quently are  in  full  operation  when  such  a  spleen  is  removed. 
After  partial  splenectomy  these  conditions  do  not  arise 
(Jordan).  Changes  can  be  prevented  after  splenectomy  by 
the  administration  of  tablets  of  extract  of  spleen  and  red  bone- 
marrow  (Bal  lance). 

Abdominal  Hernia  or  Rupture. — This  condition  is  the 
protrusion  of  a  viscus  or  part  of  a  viscus  from  the  abdominal 
cavity.  ]\IacCormac  says  the  term  implies  that  the  protruded 
viscus  is  covered  with  integument ;  hence  a  protrusion  of 
viscera  through  a  wound  does  not  constitute  a  hernia.  A 
hernia  has  three  parts — the  sac,  the  sac-contents,  and  the 
sac-coverings.  The  sac  is  formed  of  peritoneum.  A  con- 
genital sac  is  due  to  developmental  defect,  and  is  found 
only  in  the  inguinal  or  umbilical  region.  An  acquired  sac 
is  due  to  intra-abdominal  pressure  bulging  the  peritoneal 
covering  of  the  internal  abdominal  ring  and  converting  it 
into  a  pouch.  The  sac  comprises  a  body,  a  neck,  and  a 
mouth.  A  sac  once  formed  is  almost  certain  to  persist, 
because  it  adheres  by  its  outer  surface  to  surrounding  parts, 

1  Ballance,  in  Practitioner,  April,  1S9S;  H.  Martyn  Jordan,  in  Lancet,  Jan. 
22,  1898. 


858      DISEASES  AND   INJURIES   OF   THE  ABDOMEN. 

and  hence  the  sac  of  a  hernia  is  usually  irreducible  even  when 
the  contents  are  reducible.  The  neck  of  the  sac  is  due  to  the 
constriction  through  which  the  sac  passes ;  it  becomes  fur- 
rowed and  folded,  and  the  adhesion  of  these  folds  causes 
thickening  and  rigidity.  Hernia  of  the  bladder  or  of  the 
cecum  has  no  sac,  or  but  a  partial  sac.  The  contoits  of  the 
sac  depend  chiefly  on  the  situation,  a  portion  of  the  ileum 
being  the  usual  contents.  The  colon,  the  stomach,  the  great 
omentum,  the  bladder,  and  other  structures  may  enter  the 
hernial  sac.  An  enterocele  contains  only  intestine ;  an  epiplo- 
cclc  contains  only  omentum ;  an  entero-epiplocele  contains 
both  omentum  and  intestine  ;  a  cystocele  contains  a  portion 
of  the  bladder.  The  coverings  of  tlic  sac,  which  vary  with 
its  situation,  will  be  set  forth  during  the  consideration  of  special 
forms  of  hernia.  In  old  herniae  the  layers  are  never  distinct, 
fat  and  muscle  waste,  tissues  adhere,  and  the  skin  stretches 
and  atrophies.  The  sac  of  a  hernia  occasionally  becomes 
tubercular.  This  condition  arises  in  old  hernise.  It  may 
either  remain  local  in  the  hernial  sac  or  spread  to  the  general 
peritoneum.  Renault  tells  us  that  tuberculosis  of  a  hernia 
is  made  manifest  by  increase  in  size,  pain  on  pressure,  and 
loss  of  body-weight. 

Causes  of  Hernia. — The  male  sex  is  most  liable  to  hernia. 
It  occurs  at  all  periods  of  life,  and  hereditary  predisposition 
sometimes  seems  to  exist.  Excessive  length  of  the  mesen- 
tery' has  been  assigned  as  a  cause.  In  some  instances  a  mass 
of  fat  forms  and  appears  before  the  hernia,  and  seems  to  bear 
a  causative  relation  to  it.  Lucas-Championniere  explains  this 
as  follows  :  when  a  person  begins  to  take  on  fat,  it  is  de- 
posited not  only  under  the  skin,  but  also  in  the  omentum, 
mesenteiy,  and  subperitoneal  tissues.  This  semifluid  fat  is 
easily  influenced  by  pressure.  The  deposit  of  fat  within  the 
abdomen  lessens  the  size  of  that  cavity,  intra-abdominal 
pressure  is  increased,  and  fat  protrudes  at  any  weak  spot  in  the 
wall.  The  protruding  mass  of  fat  adheres  to  and  makes  trac- 
tion upon  the  peritoneum,  and  this  membrane  is  drawn  upon 
to  form  a  sac,  and  the  sac  is  surrounded  by  fat.  This  method 
of  formation  is  frequently  noticed  in  umbilical  hernise,  and 
occasionall}-  in  inguinal  hernise.  Any  laborious  occupation 
predisposes  to  rupture.  Any  condition  which  weakens  the 
abdominal  wall  predisposes  (muscular  relaxation  from  ill- 
health,  relaxation  of  abdominal  walls  following  the  termi- 
nation of  pregnancy,  the  removal  of  a  large  tumor,  or 
tapping  for  ascites,  and  wounds  or  abscesses  of  the  ab- 
dominal wall).     The  exciting  cause  is  muscular  effort  (strain- 


ABDOMIXAL    HERXIA    OR   RUPTURE.  859 

in^  at  stool,  coughing,  lifting  weights,  jumping,  the  sexual 
act  and  straining  to  make  water).  All  congenital  herniae  are 
due  to  structural  defects.  Herniae  are  divided  clinically  mto 
reducible,  in-cdiiciblc,  incarcerated,  infiamed,  and  strangu- 
lated. 

Reducible  Hernia.— In  this  form  of  hernia  the  contents 
of  the  sac  can  be  reduced  into  the  abdominal  cavit}-.  At  a 
known  hernial  opening  the  patient  has  a  smooth  enlarge- 
ment (narrower  aboxe  than  below),  which  began  to  grow 
above  and  extended  downward.  A  distinct  neck  can  olten 
be  felt.  In  enterocele,  straining,  lifting,  or  standing  en- 
larges the  mass  ;  the  protrusion  becomes  smaller  and  may  dis- 
appear on  Iving  down  ;  cough  causes  impulse  m-_su£cu.ssiorL; 
the  protrusion  is  elastic,  and  on  reductloiniie  mass  suddenly 
disappears  and  there  is  a  gurgling  sound.  In  epiplocele  the 
mass  is  often  irregular  and  compressible,  and  feels  boggy 
rather  than  elastic;  muscular  effort  does  not  have' much 
influence  in  enlarging  it;  impulse  on  coughing  is  shght ; 
percussion  gives  a  dull  note,  and  reduction  is  accom- 
plisHed^grad^ually  and  produces  no  gurgling  somid.  In 
entero-epiplocele'  some  parts  of  the  mass  are  smooth, 
elastic,  and  tympanitic,  others  are  dull  on  percussion,  irreg- 
ular, and  flabby :  but  the  diagnosis  of  this  especial  form  is 
uncertain.  The  victims  of  reducible  hernia  complain  of 
some  pain  on  exertion,  of  dyspepsia,  and  often  of  constipa- 

tion. 

When  a  hernia  is  beginning  to  form  a  patient  complains 
of  muscular_BainJll  the  lower  abdomen,  and  this  condition 
may  exist  for  weeks  before  it  is  recognized  that  a  hernia  is 
present.  An  inguinal  hernia  should  be  recognized  before  it 
protrudes  from  the  external  ring.  The  tip  of  the  finger  is 
inserted  in  tTie  ring  and  the  patient  is  asked  to  cough.  If 
a  hernia  has  entered  the  canal,  succussion  will  be  detected 
on  coughing.  In  a  healthy  man  the  external  ring  should 
admit  the  tip  of  the  little  finger,  but  not  the  end  of  the  index- 
finger.  If  the  end  of  the  index-finger  can  be  made  to  enter 
the^ring.  that  aperture  is  dilated ;  and  even  if  there  is  no  hernia 
in  the^canal.  in  future  a  hernia  will  probably  descend.  In  a 
man,  if  the  surgeon  desires  to  examine  the  ring,  he  inverts 
the  skin  of  the  scrotum  over  the  finger  and  carries  the  finger 
to  or  in  the  ring. 

Treatment  of  Reducible  Hernia. — Palliative  Treatment. — 
Prevent  constipaiimi.  forbid  suddeii_strains-and-v4eleftt-exer- 
cise,  an"d' order  a  truss.  The  continued  employment  of  a 
truss,  especially  in  young  persons,  may  bring  about  a  cure. 


86o      DISEASES  AND   INJURIES   OF   THE  ABDOMEN. 

The  day  truss  should  be  appHed  before  rising  in  the  morn- 
ing and  be  removed  after  lying  down  at  night,  when  a  light 
truss  should  be  substituted.  A  special  truss  is  applied  before 
bathing.  In  very  fat  people  there  is  always  trouble  in 
adjusting  a  truss.  A  femoral  hernia  is  more  difficult  to  keep 
reduced  tlian  an  inguinal  hernia.  In  a  hernia  in  which  the 
gut  is  replaceable,  but  a  portion  of  omentum  is  irreducible, 
it  is  difficult  to  maintain  reduction  of  the  gut  with  a  truss, 
and  an  operation  should  be  performed.  In  an  oblique  in- 
guinal hernia  the  pad  of  the  truss  fits  over  the  internal 
abdominal  ring ;  in  a  direct  inguinal  hernia,  over  the  external 
abdominal  ring ;  in  a  femoral  hernia,  over  the  fem.oral  ring 
at  the  level  of  Gimbernat's  ligament.  MacCormac's  method 
of  measuring  for  a  truss  is  as  follows  :  in  either  inguinal  or 
femoral  hernia  start  the  tape  from  the  loivcr  part  of  the 
hernial  opening,  carry  it  up  to  the  anterior  superior  iliac 
spine  of  the  same  side,  then  take  it  around  the  body,  one  inch 
below  the  crest  of  the  ilium,  to  the.  other  anterior  superior 
iliac  spine,  and  then  to  the  upper  part  of  the  hernial  opening.^ 
A  well-fitting  truss  will  keep  the  hernia  up  even  when  the 
patient  sits  in  a  position  to  relax  the  abdominal  walls  and 
coughs  and  strains.  A  truss  is  always  uncomfortable  at  first, 
but  a  person  usually  becomes  accustomed  to  it.  It  should 
be  kept  scrupulously  clean,  and  it  is  well  to  dust  borated 
talc  powder  upon  the  skin  under  the  pad  at  least  once  a  da}'. 
A  truss  which  does  not  keep  the  hernia  up  or  which  causes 
pain  does  harm.  Too  strong  a  spring  tends  to  enlarge  the 
hernial  orifice,  and  thus  aggravates  the  case.  Even  after  an 
apparent  cure  with  a  truss  the  instrument  must  be  worn  for 
a  long  time. 

Radical  trcatvicnt  seeks  to  permanently  cure  by  plugging 
the  mouth  of  the.  sac  or  by  obliterating  the  canal  of  descent. 
Radical  operations  should  be  performed  when  a  strangulated 
hernia  is  operated  upon,  in  ordinaiy  cases  of  reducible  hernia 
in  which  a  truss  is  very  painful  or  does  not  keep  the  bowel 
up,  in  most  cases  of  irreducible  hernia,  and  in  any  case 
which  has  occasional  attacks  of  obstruction.  It  used  to  be 
believed  that  a  cure  would  fail  if  the  subject  was  under  three 
years  of  age,  but  Coley  and  others  have  proved  that  it  is  a 
very  successful  operation  in  children.  In  any  operation  for 
the  radical  cure  of  hernia  always  remember  that  the  bladder 
may  be  part  of  the  hernia,  and  be  on  the  lookout  for  it.  As 
a  rule,  it  is  covered  with  cellular  fat,  which  differs  in  color 
and  consistence  from  omental  fat  and  from  other  fat  which 

'  Treves's  Manual  of  Surgery,  "  Hernia." 


ABDOMIXAL    HERXIA    OR   RUPTLRE.  86 1 

ma\'  be  found  about  a  hernia.  It  was  the  author's  misfor- 
tune to  open  a  bladder  in  operating  upon  an  inguinal  hernia. 

Lannclonguc' s  Method. — Lannelongue  has  for  certain  cases 
returned  to  the  old  injection  plan,  using  a  lo  per  cent, 
solution  of  chlorid  of  zinc  instead  of  white  oak  bark.  The 
hernia  is  first  reduced  and  is  held  up  b}'  an  assistant  who 
closes  the  internal  ring  with  a  finger,  and  also  holds  the  cord 
aside.  Several  injections  of  lO  minims  each  are  thrown  in  the 
region  of  the  internal  pillar,  the  region  of  the  external  pillar, 
and  into  the  canal  behind  and  outside  of  the  cord.  The  sur- 
geon must  be  careful  that  no  zinc  solution  escapes  into  the 
subcutaneous  tissue.  The  effect  of  the  chlorid  of  zinc  is  to 
cause  the  formation  of  quantities  of  fibrous  tissue.  It  is 
scarcely  to  be  expected  that  a  cure  so  produced  will  be  per- 
manent in  an  adult,  though  it  may  be  in  a  child. 

2Iaccwe)i s  Operation  for  higidnal  Hernia. — The  instru- 
ments required  in  this  operation  are  scalpels,  a  blunt,  straight 
bistoury,  a  dr}'  dissector,  a  grooved  director,  scissors,  a 
hernia-director,  hernia-needles  (Fig.  321),  dissecting-forceps, 
toothed  forceps,  hemostatic  for- 
ceps, an  aneurysm-needle,  blunt 
hooks,  half-curved  needles,  nee- 
dle-holder, and  chromicized  cat- 
gut sutures.  The  patient  lies 
recumbent,  the  thigh  being  ab- 
ducted and  parth'  flexed  and  rest- 
ing on  a  pillow  beneath  the  knee.         ^"""^^'-A  " " '  r '^;."r: "  •  "• 

£>  C  hinged  herma-airector. 

The    bowel   is    reduced,  and    an 

incision  three  inches  long  is  made  in  the  direction  of  the 
inguinal  canal,  the  center  of  the  incision  corresponding  to 
the  external  ring.  The  sac  is  freed  from  its  attachments 
below  and  is  lifted  up.  The  surgeon  introduces  a  finger  into 
the  inguinal  canal  and  separates  the  sac  from  the  cord  and 
from  the  walls  of  the  canal,  and  then  carries  the  finger  through 
the  internal  ring  and  separates  the  peritoneum  for  one  inch 
about  the  periphery'  of  this  aperture  (Fig.  322,  a).  A  chromi- 
cized catgut  stitch  is  fastened  to  the  lowest  portion  of  the  sac, 
and  is  passed  through  the  sac  several  times,  so  that  pulling  on 
the  stitch  will  purse  the  sac  (Fig.  322,  b).  The  free  end  of 
this  stitch  is  carried  through  the  internal  ring  into  the  belly, 
and  is  pushed  out  through  the  abdominal  muscles  one  inch 
above  the  internal  ring,  the  skin  being  pushed  aside  so  as  to 
escape  perforation  by  the  needle.  The  thread  is  tightened  so 
as  to  fold  up  the  sac  and  pull  it  into  the  belly.  This  plugs 
the  ring  (Fig.  322,  c).     The  thread  is  handed  to  an  assistant 


862      DISEASES  AND   INJURIES   OF   THE  ABDOMEN. 


to  keep  tight  until  the  sutures  are  introduced  into  the  ring, 
when  the  sac  is    permanently    anchored    by  taking    several 


^::a\ 


Fig.  322.— Macewen's  operation  for  radical  cure  of  ing-umal  hernia  ■  a  stripping  of 
the  sac  ;  b,  purse-string  suture  ;  c,  fastening  the  purse-string  suture  ,  d,  passing  'and  e  tying 
the  sutures  for  the  internal  ring.  »   .»     &> 


stitches  in  the  external  oblique  muscle.  A  strono-  catgut 
suture  is  passed  with  a  Macewen  needle  through  the  con- 
joined tendon  from  below  upward,  the 
ends  of  this  suture  being  carried  through 
Poupart's  ligament  and  the  outer  border 
of  the  internal  ring  from  within  outward. 
This  suture  is  tightened  and  closes  the 
internal  ring.  The  external  ring  is  su- 
tured and  the  skin  is  stitched  together 
(Fig.  322,  e). 

In  congenital  hernia  the  sac  is  divided 
in  its  middle,  and  the  lower  part  is  closed 
by  stitches  of  chromic  catgut,  forming  a 
tunica  vaginalis.  The  upper  part  of  the 
sac  is  slit  posteriorly  to  permit  the  escape 
of  the  cord,  and  is  closed  by  stitches  of  chromic  catgut.  The 
operation  is  finished  as  in  the  acquired  form  (Fig.  323).     After 


Fig.  323. — Macewen's 
operation  for  the  radical 
cure  of  congenital  hernia. 


ABDOMIXAL   IIEKXIA    OR   RUPTURE. 


863 


this  operation  the  patient  should  stay  in  bed  for  about  four 
weeks,  and  must  not  work  for  eight  or  nine  weeks.      \\  ork- 
men  after  this  operation   should  alwaj's    wear  a  pad  and  a 
spica  bandage.    Children  require  no  pad.    Xe\-er  apply  a  truss, 
as  strong  pressure  will  produce  atrophy  of  the  curative  scar._ 
Bassini's   and   Halstcd's    Operations   for   Inguinal    Hcr^ 
jiia. — Bassini's  operation  displaces  the  spermatic  cord  from 
the  old   canal   and   places  it  in  a  new  canal,  and  this    new 
canal  is  oblique.     The  instruments  employed  are  the  same 
as  for  Macewen's  operation,  excepting  the  special   needles, 
which    are  not  needed.       Hagedorn   needles    are  employed 
to    insert   the    stitches.      The    suture-material    is    kangaroo- 
tendon  or  chromicized  catgut.       Silk   or  silver  wire  is   apt 
to  make  trouble— it  may  be  long  after  the  operation.     The 
position   is  the   same  as  in  ^lacewen's  operation.     Aninci- 
sion  is  made  from  the  extenial_ring_toj_gomt  external  to 
the  internaTring"     The  ^ac  is^posed  and  twisted,  its  neck  is 
'ligated,  and  it  is  cut  off  in  front 
of  the  ligature.    Tli^spermatic 
coed  is  lifted  (Fig.  324,  a);  the 
border  of  the  rectus    muscle, 
the  edges  of  the   internal  ob- 
lique   and     the     transversalis 
muscles,  and  the  transversalis 
fascia,  are  sutured  to  the  lower 
shelf  of  Poupart's  ligament  be- 
low the  cord  (Fig.  324,  b).    Tlie 
border  of  the  external  obHque 
is  sutured  to  the  upper  shelf  of 
Poupart's   ligament  above  the 
cord_  (Fig.  324,  c).    The_£ldnjs 
sutur^  b)r  .jntfixiupted  stitches 
^  silkworm-gut  or  the  edges 
qf^the  wound  are  approximated 
by  a  subcuticular  stitch  of  cat- 
gut   or    silver.  wire=     In    this 
operation  the  author  is  accus- 
tomed to  treat  the  sac  as  in   ^lacewen's  operation,  carr^'ing 
out  the  rest  of  the  procedure  as  directed  above.     In  a  pure 
Bassini  operation  the  funnel-shaped  depression  in  the  peri- 
toneum at  the  point  of  emergence  of  the  cord  remains  and 
predisposes  to  hernia,  but  the  use  of   Macewen's    plan    for 
treating  the  sac  obviates  this.     Halsted's  operation  consists 
in  incising  the  external  oblique,  incising_tlie_Jower_edge  of 
the  internal  oblique,  opening  the  sac  above  the  level  of  the 


Fig.  32 


A-c. — Bassini's  operation  for  the 
cure  of  ingoiinal  hernia. 


864      DISEASES  AND   INJURIES   OF   THE   ABDOMEN. 

internal  rini^,  cutting  the  sac  across,  suturing  the  wound  in 
the  peritoneum  as  a  hiparotomy  wound  is  sutured,  .grasping 
tlieJi:ee_enid_ofjhe_sac,aiid separating  the  sac  from  the  cord, 
resecting  some  of  the  large  veins  to  lessen  the  diameter  of 
the  cofd7  placing  the  cord  between  the  external  oblique 
muscle  and  the  integument,  and  suturing  the  muscular 
structures  beneath  the  cord  with  mattress-sutures  of  silver 
wire,  and  closing  the  skin  incision  with  a  subcuticular  suture. 
Halsted's  subcuticular  suture  is  almost  identical  with  the 
subcuticular  suture  of  Kendal  Franks  of  Dubhn.  Chas- 
siagnac,  as  long  ago  as  185  i,  recommended  a  subcutaneous 
suture.  Halsted's  suture  is  not  subcutaneous,  but  subcu- 
ticular or  intradermal.  The  material  employed  may  be 
silver  wire,  catgut,  or  silk.  It  is  inserted  by  means  of  a 
medium-sized  Hagedorn  needle  held  in  a  needle-holder.  It 
is  carried  through  the  derma  at  the  one  margin  of  the  wound 
and  then  of  the  other,  and  so  on.  When  it  is  inserted  the 
ends  of  the  suture  are  pulled  and  the  wound  is  approxi- 
mated. In  introducing  this  suture  the  needle  does  not  pass 
through  the  epiderm,  and  hence  there  is  no  danger  of  infect- 
ing the  wound  with  the  staphylococcus  epidermidis  albus. 
Halsted's  operation  makes  a  new  internal  ring  through  the 
internal  oblique  and  external  oblique  muscles,  and  makes  a 
new  inguinal  canal.  Halsted  and  Bloodgood  have  noticed 
that  removal  of  the  cord  from  its  bed  may  be  followed  by 
epididymitis,  or  even  atrophy  of  the  testicle;  hence  in  many 
cases  they  leave  the  cord  in  its  bed,  and  transplant  or  resect 
the  veins. 

KocJicfs  Operation. — Kocher  exposes  the  aponeurosis  of 
the  external  oblique,  makes  a  small  incision  through  the 
aponeurosis  above  and  external  to  the  internal  ring,  and 
draws  the  sac  through  this  incision  and  sutures  it  in  place. 

Fozvlcrs  operation  is  as  follows  :  an  incision  is  made 
parallel  with  Poupart's  ligament  from  the  spine  of  the  pubis 
to  the  level  of  the  internal  ring,  and  a  flap  is  turned  up.  The 
inguinal  canal  is  opened  and  the  sac  and  cord  isolated.  The 
sac  is  opened,  its  contents  reduced,  it  is  cut  off,  and  its 
edges  grasped  with  forceps.  The  deep  epigastric  artery  and 
vein  are  sought  for,  each  is  tied  in  two  places  and  divided 
between  the  ligatures.  The  index-finger  is  introduced  into 
the  belly,  and  on  this  as  a  guide  the  floor  of  the  canal  is 
divided  (transversalis  fascia,  subserous  tissue,  and  peritoneum). 
The  cord  is  placed  in  the  peritoneal  cavity.  The  edges  of 
the  opening  are  sutured  so  that  broad  serous  surfaces  are 
approximated,    through-and-through    sutures    being    passed 


ABDOMLVAL    HERNIA    OR    RUPTURE.  865 

from  side  to  side.  The  cord  is  brought  out  at  the  inner 
end  of  the  incision,  the  lower  angle  of  the  cut  being  at  such 
a  level  that  the  cord  curves  upward  and  forward  as  it  leaves 
the  abdomen.  The  inguinal  canal,  the  gap  in  the  aponeuro- 
sis, and  the  skin-wound  are  closed.^ 

After  a  radical  cure  by  any  method  the  patient  should  re- 
main in  bed  four  weeks. 

Radical  Cure  of  Umbilical  Hernia. — Make  an  elliptical 
incision  through  the  skin  around  the  mass.  Endeavor  to 
separate  the  sac  from  the  superficial  tissues.  If  this  cannot 
be  done,  open  the  sac  and  separate  it  from  the  contents. 
Even  if  the  sac  can  be  stripped  from  the  skin,  always  open 
it  and  separate  the  contents.  Return  any  bowel  which  may 
be  present,  and  do  not  forget  that  there  may  be  a  small 
portion  of  bowel  completely  encased  in  omentum.  Tie  into 
segments  and  cut  off  the  superfluous  omentum  and  return 
the  stump  into  the  belly.  Excise  the  umbilicus  (omphalec- 
tomy). Suture  the  peritoneum  with  a  continuous  catgut 
suture.  Close  the  musculofascial  wall  with  two  layers  of 
interrupted  kangaroo-tendon  sutures  or  one  layer  of  silver 
wire  mattress-sutures.  Close  the  skin  by  interrupted  sutures 
of  silkworm-gut  or  a  subcuticular  stitch. 

Radical  Qtre  of  Femoral  Hernia. — Cheyne  ligates  the 
neck  of  the  sac,  stitches  the  stump  to  the  abdominal  wall, 
dissects  out  a  flap  from  the  pectineus  muscle,  stitches  this 
flap  to  Poupart's  ligament  and  to  the  abdominal  wall,  and 
thus  fills  up  the  crural  canal.  Bassini  makes  an  incision 
parallel  with  Poupart's  ligament,  ties  the  neck  of  the  sac, 
cuts  below  the  ligature,  and  returns  the  stump  into  the  belly. 
He  attaches  by  deep  sutures  Poupart's  ligament  to  the  pec- 
tineal aponeurosis  as  high  up  as  the  pectineal  eminence,  the 
cord  or  round  ligament  being  drawn  out  of  the  way.  Super- 
ficial sutures  are  passed  between  the  pubic  portion  and  the 
iliac  portion  of  the  fascia  lata. 

The  operation  of  Fabricius  is  as  follows  :  an  incision  is 
begun  over  the  pubic  spine  and  is  carried  outward  for  five 
inches  parallel  with  Poupart's  Hgament.  The  sac  is  exposed, 
isolated,  and  opened,  and  its  contents  are  reduced,  its  neck 
is  ligated,  the  sac  is  cut  off,  and  the  stump  is  dropped  back. 
An  incision  is  now  made  below  Poupart's  ligament  so  as  to 
separate  this  structure  and  the  fascia  lata,  and  the  flap  of 
fascia  is  turned  down.  The  crural  sheath  and  the  vessels  are 
retracted,  and  the  origin  of  the  pectineus  muscle  is  sutured 
to    Poupart's  ligament.     The   flap  of  fascia    lata  is  sutured 

^  Annals  of  Surgery,  Nov.,  1897. 


866      DISEASES  AND   INJURIES   OF   THE  ABDOMEN. 

to  the  aponeurosis  of  the  external  oblique,  and  the  skin  is 
sutured. 

Irreducible  Hernia. — The  swelling  in  irreducible  rupture 
presents  the  usual  evidences  of  hernia,  shows  an  impulse  on 
coughing,  but  cannot  be  replaced  in  the  abdomen.  Some- 
times a  portion  is  reducible  and  a  portion  is  irreducible.  A 
hernia  may  become  irreducible  because  of  the  size  of  the 
mass,  because__of  adhesions,  or  because  of  great  growth  of 
omental  fat.  An  TrTeducible  hernia  is  liable  to  be  bruised 
an3^rol:ause  much  distress  and  pain,  and  is  always  a  menace 
to  life  because  of  the  danger  of  obstruction  and  strangulation. 
It  was  formerly  the  custom  to  support  a  small  irreducible 
hernia  by  a  hollow  padded  truss ;  a  large  hernia  of  this  variety 
may  be  carried  in  ajbagrlruss.  The  patient  must  not  take  very 
active  exercise,  must  keep  the  bowels  regular,  and  must  live 
upon  a  plain  diet.  Most  cases  of  irreducible  hernia  should 
be  treated  by  operation. 

Incarcerated  or  Obstructed  Hernia. — Obstruction  takes 
place  by  the  damming  of  feces  or  of  undigested  food, 
the  fecal  current  being  arrested,  but  the  blood-current  in 
the  wall  of  the  bowel  being  undisturbed.  Incarceration 
is-commiDhesFln  irreducible  hernia,  umbilical  hernia,  and 
during  the  existence  of  constipation.  The  tumor  enlarges 
and  becomes  tender,  painful,  and  dull  on  percus_sion;  press- 
ure diminishes  it  in  size ;  it  is  irreducible,  but  still  pre- 
sents impulse  on  coughing.  The  abdomen  is  somewhat 
distended"~3nTd- -pairtfuh;  there  are  nausea,  constipation,  and 
not  unusually  slight  vomiting.  Constitutional  disturbance 
is  slight  and  constipation  is  not  absolute,  gas  at  least 
usually  passing.  Vomiting  is  not  fecal.  The  trcat))ieiit  is 
rest  in  bed  in  a  position  to  relax  the  belly,  an  ice-bag  over 
the  hernia,  and  a  little  opium  for  pain.  Do  not  give  a 
particle  of  food  fox.-twenty-four  hours ;  when  the  active 
symptoms  subside  give  an  enema,  and  after  this  acts  a. dose 
of  castor  oil.  Do  .JiQt„ernplpy  taxis,  as  bruising  the  bowel 
may  produce  strangulation. 

Inflamed  Hernia. — Inflammation  of  a  hernia  is  local  peri- 
tonitis due  to  injury  of  an  irreducible  hernia.  The  mass 
becomes  tender,  painful,  and  hot.  In  enterocele  much  fluid 
forms  ;  in  epiplocele  the  mass  becomes  hard.  The  hernia 
cannot  be  reduced ;  there  is  constipation,  often  vomitirig, 
usuall}'  fever,  but  the  mass  still  shows  impulse  on  coughing. 
Vomiting  is  not  fecal.  Some  gas  is  usuall)^  passed  through  the 
bowels.  Constitutional  symptoms  are  slight.  T\\^  treatment 
usually  recommended  is  rest  in  bed  with  abdominal  relaxa- 


ABDOMINAL   HERNIA    OR   RUPTURE.  86/ 

tion.an  ice-bag  to  the  tumor,  a  small  amount  of  opium  by  the 
mouth  if  pain  is  severe,  an  enema,  and  when  this  acts  a  saline. 
In  an  inflamed  hernia  there  is  great  danger  of  strangulation, 
and  operation  should  be  performed  in  preference  to  relying 
upon  the  conservatix'e  plan. 

Strangulated  hernia  is  a  condition  in  which,  if  the  hernia 
contains  bowel,  not  only  is  the  fecal  ciVcuiation, .arrested, 
but  the  circulation  of  blood  in  the  bowel-wall  is  also  ar- 
rested. The  bowel  is  irreducible  and  obstructed,  and  the 
blood  ceases  to  circulate.  If  the  hernia  contains  omentum, 
the  omental  vessels  are  tightly  constricted.  Strangulation 
is  commonest  in  oldjngyiiial  ruptures  in  active,  middle-aged 
men,  and  is  more  frequent  in  enteroceles.than  in  epiploceles. 
It  may  be  due  to  entry  into  the  sac  of  more  intestine  or 
omentum,  which  has  been  forced  down  by  sudden  movement 
0£  violent  effort.  It  may  be  due  to  active  peristalsis  or  to 
congestion,  and  it  may  arise  from  inflammation  or  from  in- 
carceration. The  constriction  is  usually  at  the  neck  of  the 
sac,  m  the  outside  tissues,  or  even  in  the  sac  itself  In  an 
hour-glass  hernia  the  constriction  is  in  the  body  of  the  sac. 
Adhesions  within  the  sac  may  cause  strangulation.  Spas- 
modic contraction  of  the  tissues  about  the  neck  of  the  sac 
is  an  exploded  hypothesis.  When  strangulation  once  begins 
the  hernia  swells,  a  furrow  forms  on  the  bowel  at  the  seat 
of  constriction,  the  bowel  and  omentum  below  the  con- 
striction become  deeph^  congested  and  edematous,  and, 
finally,  the  hernia  passes  into  a  state  of  moist  gangrene. 
The  gangrene  may  be  in  spots  or  the  entire  mass  may  be 
gangrenous.  The  sac  is  apt  to  inflame,  and  inflammation 
produces  fluid  and  lymph  ;  serum  accumulates  in  the  sac, 
being  first  clear,^  then  bloody.,  and  finallyj^rown  _and^_^foul. 
When  gangrene  is  once  established  the  bowel  is  in  danger  of 
rupturing.  At  the  point  of  contraction  there  may  be  a  line 
of  ulceration.  A  strangulated  femoral  hernia,  becomes  gan- 
grenous more  rapidly  than  does  a  strangulated  inguinal  hernia. 

Symptoms. — An  individual  who  has  a  hernia  is  seized  with 
pain  in  and  about  the  hernia  and  with  violent  colicky  pain 
about  the  umbilicus,  and  the  paroxysms  of  colic  become  more 
and  more  frequent,  until  finally  the  pain  may  become  con- 
tinuous. The  hernia  is  found  to  be  irreducible  ;  larger  than 
usual,  tender,  painful,  dull  on  percussion,  without  impulse  on 
coughing,, and  the  skin  above  it  may  be  reddened.  Eructa- 
tions of  gas  are  frequent  and  generally  uncontrollable 
vomiting  and  prostration  come  on.  Vomiting',~as  a  rule, 
is  ari  early  symptom,  and  one  which  increases  in  severity. 


S6S      DISEASES  AND   INJURIES   OF  THE  ABDOMEN. 

Occasionally  it  only  follows  the  swallowing  of  liquids. 
Not  unusually  there  is  retching  rather  than  vomiting.  In 
rare  cases  it  does  not  arise  for  twenty-four  to  forty-eight 
hours.  During  the  course  of  a  strangulation  vomiting 
may  cease  for  a  day  or  more,  and  it  not  unusually  ceases 
toward  the  end,  when  prostration  is  profound.  The  early 
vomiting  is  due  to  reflex  causes,  the  later  vomiting  is  due  to 
waves  of  peristalis  which  produce  regurgitation  (Macread\^). 
The  vomiting  is  first  of  the  alimentary  contents  of  the  stomach, 
next  of  mucus  and  bilious  matter,  and  finally  of  the  contents 
of  the  small  bowel  (fecal  or  stercoraceous  vomiting).  Ster- 
coraceous  vomiting  rarely  arises  until  strangulation  has  lasted 
fort}'-eight  hours,  and  may  not  appear  until  much  later.  "  It 
is  seldom  met  with  in  inguinal,  more  often  in  femoral, and  more 
often  still  in  obturator  hernia  "  (Macready).  Prostration  is  a 
marked  symptom  of  a  strangulated  hernia,  and  it  increases 
hour  by  hour  and  goes  on  to  collapse.  Early  in  the  case 
there  may  be  some  elevation  of  temperature,  but  later  it 
becomes  normal  or  subnormal.  The  pulse  is  sma]l,irr€gti-- 
lar,  rapid,  and  very  weak ;  the  extremities  cold ;  the  face 
Hippocratic.  Constipation  is  absolute,  no  gas  even  being 
passed,  though  in  the  very  beginning  there  may  be  some 
diarrheal  passages  from  below  the  constriction.  Diarrhea 
with  pain  at  a  hernial  orifice  should  always  excite  suspicion 
that  strangulation  may  be  beginning.  The  urine  is  scanty 
and  high-colored,  and  contains  only  a  small  amount  of  the 
chlorids ;  the  tongue  becomes  dry  and  brown  ;  the  thirst  is 
torturing ;  and  the  patient  often  has  an  urgent  desire  to  go 
to  stool.  Pains  in  the  abdomen  and  in  the  hernia  become 
violent,  and  collapse  rapidly  increases.  When  gangrene  be- 
gins the  symptoms  apparently  lessen  in  violence  :  there  is  a 
"  delusive  calm."  Vomiting  usually  ceases,  though  regurgi- 
tation may  take  its  place ;  hiccough  begins  ;  the  pain  abates 
or  disappears  ;  the  pulse  becomes  very  feeble  and  intermittent; 
collapse  deepens,  and  delirium^is  usual.  It  is  a  safe  clinical 
rule  that  in  strangulatedliernia  cessation  of  pain  without  the 
relief  of  constriction,  the  disappearance  of  the  lump,  or  the 
use  of  opiates  means  that  gangrene  has  begun.  In  some 
cases  of  strangulation  there  are  muscular  cramps  in  the  legs 
(Berger).  In  children  convulsions  are  not  unusual.  In  a 
pure  omental  hernia  strangulation  produces  similar  but  less 
decided  symptoms.  It  may  be  that  only  a  portion  of  the  cir- 
cumference of  the  bowel  is  caught  and  constricted  in  a  hernial 
orifice.  Such  a  condition  is  encountered  occasionally  in  the 
femoral  ring,  and  is  called  partial  enterocele  or  Richter's  hernia. 


ABDOMIXAL   IIEKXIA    OR   RUrrURE.  869 

The  name  Littre's  hernia  so  often  given  to  this  condition  is 
wron"-.     What    Littre   described   was  a  hernia   of   Meckel's 
diverSculum.     In  a  strangulated  Richter's  hernia    constipa- 
tion is  rarely  absolute  and'a  protrusion  is  often  undiscovered. 
Treatment.— \\\    treating    strangulated    hernia,  place    the 
patient  upon  his  back,  bend  the  knees  over  a  pillow,  and 
rigidly    interdict  the  administration  of  food.     An  attempt  is 
to^  be    made  to  effect  reduction  by  gentle   manipulation  or 
taxis.     In  applving  taxis  to  a  femoral  or  inguinal  hernia,  flex 
and  adduct  the  thigh  of  the  affected  side.     In  applying  taxis 
to  an   umbilical  hernia,  both  thighs  should  be  flexed  upon 
the   abdomen.     Always  lower  the  shoulders  and  head  and 
raise  the  pelvis,  and  accomplish  this  by  lifting  the  foot  of  the 
bed  and  placing  pillows   under  the  pelvis.     In  some  cases 
raise  the  entire  body,  the  head  being  lowered.     Grasp  the 
neck  of  the  sac  with  the  fingers  and  thumb  of  one  hand,  and 
employ  the  other  hand  to  squeeze  the  hernia  and  urge  it 
toward  the  belly.     In   direct  inguinal    hernia  the    pressure 
should  be  backward  and  a  little  upward  ;  in  umbilical  hernia 
it  should  be  backward ;  in  oblique  inguinal  hernia  it  should 
be   upward,   outward,   and  backward;    in    femoral  hernia  it 
should  be  'downward  until  the  hernia  enters  the  saphenous 
opening,    and    then    "  backward    toward    the    pubic    spine " 
(MacCo'rmac).     If  the  bowel  is  reduced,  it  passes  from  the 
hand  with  a  sudden  slip  and  enters  the  belly  with  an  audible 
gurgle ;  omentum,  when  reduced,  slowly  glides  back  without 
gurgling.     Taxis  is  never  to  be  continued  long,  and  it  is  not 
even  to''  be  attempted  in   cases  of  great   acuteness,  in  cases 
where    strangulation    has    lasted   for  several   days,  in  cases 
known  to  have  been  previously  irreducible,  in  cases  associated 
with  stercoraceous  vomiting,  or  in  an  inflamed  or  gangrenous 

hernia. 

If  taxis  fails,  obtain  the  patient's  permission  to  operate. 
Anesthetize;  try  taxis  again  while  ether  is  being  dropped 
upon  the  hernia  to  cause  cold  ;  if  reduction  fails,  at  once  per- 
form herniotomv.  Taxis  possesses  certain  dangers :  it  may  rup- 
ture the  bowel  \  it  may  rupture  the  neck  of  the  sac  and  force 
the  bowel  through  the  rent ;  it  may  strip  the  peritoneum  from 
around  the  hernial  orifice  and  force  the  bowel  between  the 
detached  peritoneum  and  the  abdominal  wall ;  it  may  reduce 
a  hernia  into  the  belly  when  the  bowel  is  still  strangulated 
by  adhesions ;  it  may  reduce  the  hernia  en  masse  or  en  bloc, 
the  sac  and  strictured  bowel  being  forced  together  through 
the  internal  ring.  By  reduction  en  bissac  is  meant  the  forcing 
of  a  congenital    hernia  into   a   congenital   pouch   or   diver- 


870      DISEASES  AND   INJURIES   OE   THE  ABDOMEN. 

ticulum.  In  any  of  the  above  accidents  strangulation  may 
persist  after  apparent  reduction  by  taxis,  and  this  condition 
calls  for  instant  laparotomy — in  most  instances  through  the 
hernial  aperture.  If  taxis  is  successful,  put  the  patient  to 
bed,  apply  a  pad  and  bandage,  allow  the  patient  to  take  no 
food  until  vomiting  ceases,  merely  permitting  him  to  suck 
bits  of  ice,  and  keep  him  on  a  liquid  diet  for  several  days. 
At  the  end  of  the  first  week  give  solid  food.  Do  not  disturb 
the  bowels  for  a  few  days,  but  if  they  have  not  acted  at  the 
end  of  four  or  five  days,  give  a  saline  cathartic  and  an  enema. 
Herniotomy. — If  there  has  been  stercoraceous  vomiting, 
the  stomach  must  be  washed  out  before  giving  the  anesthetic, 
and  during  the  administration  of  the  anesthetic  the  head 
should  be  turned  upon  its  side.  In  most  cases  a  general 
anesthetic  can  be  given,  but  in  some  desperate  cases  it  is  not 
justifiable  to  give  ether  or  chloroform,  and  a  local  anesthetic 
must  be  used  (eucain,  cocain,  or  Schleich's  fluid).  Wrap  the 
patient  up  warm.  In  miost  cases  tr>'  gentle  taxis  for  a  brief 
time  after  the  patient  has  been  anesthetized,  and  while  ether 
is  being  dropped  upon  the  hernia  to  cause  cold.  Never  try 
taxis  if  stercoraceous  vomiting  has  occurred.  If  taxis  fails, 
at  once  resterilize  the  parts  and  operate.  The  instruments 
required  in  herniotomy  are  a  scalpel,  a  hernia-knife  and  director 
(Fig.  321,  b),  hemostatic  and  dissecting-forceps,  blunt  hooks, 
scissors,  a  dry  dissector,  partly  curved  needle,  and  a  needle- 
holder.  Drainage-tubes  should  be  ready.  In  the  operation 
the  patient  lies  upon  his  back  with  the  shoulders  raised,  the 
surgeon  standing  to  the  patient's  right  side.  In  oblique 
inguinal  hernia  it  has  been  the  custom  since  the  days  of 
Scultetus  to  raise  a  fold  of  skin  at  right  angles  to  the  axis  of 
the  external  ring  and  transfix  it,  the  wound  which  results 
being  extended  until  it  becomes  three  inches  in  length.  This 
incision  possesses  no  special  merit.  It  is  better  to  cut  from 
without  inward,  and  to  make  the  same  incision  as  for  the 
performance  of  a  radical  cure  in  a  non-strangulated  case. 
The  tissues  are  divided  until  the  sac  is  reached,  and  no 
attempt  is  made  to  specially  identify  them.  The  sac  is 
known  by  the  fat  which  usually  covers  it,  by  the  arborescent 
arrangement  of  its  vessels,  by  the  fact  that  it  can  be  pinched 
up  between  the  finger  and  thumb  and  the  layers  rolled  over 
each  other,  and  by  the  fluid  within  the  sac.  Should  the  sac 
be  opened  ?  In  ver}^  recent  cases  it  is  usually  unnecessary, 
but  if  there  is  any  doubt  as  to  the  condition  of  the  bowel,  or 
if  a  radical  cure  is  to  be  attempted,  open  the  sac  and  be 
certain  as  to  the  condition  of  its  contents.     The  general  rule 


ABDOMIXAL    HERXIA    OR   RUPTURE.  87 1 

should  be  to  open  the  sac.  The  sac  is  opened  and  the  con- 
tents examined  for  fecal  odor  (which  is  not  unusual)  and  for 
gangrenous  smell ;  the  thickness  of  the  bowel  is  estimated, 
and  the  color  and  luster  are  determined.  In  oblique  inguinal 
hernia,  nick  the  constriction  upward  and  outward,  as  shown 
in  Fig.  325.  In  direct  inguinal  hernia  the  cut  is  made 
upward  and  inward.  Always  pull  the  bowel  down  and 
examine  the  seat  of  constriction  to  see  what  damage  has  been 
inflicted  at  that  point.  If  the  bowel  glistens,  if  the  proper 
color  comes  back  after  irrigation  with  very  hot  water,  and  if 
there  are  no  spots  of  gangrene,  restore  the  bowel  to  the 
abdomen,  and  do  a  radical  cure.  If  the  bowel  is  in  a  doubt- 
ful condition,  fasten  it  to  the  incision,  apply  a  dressing,  and 
watch  the  development  of  events.  If  the  bowel  is  gan- 
grenous, our  action  depends  upon  the  condition  of  the 
patient.  If  the  patient  is  in  good  condition,  resect  the  gan- 
grenous portion,  and  perform  end-to-end  anastomosis  by 
means  of  a  Murphy  button.  If  the  patient's  condition  is  bad, 
make  an  artificial  anus,  and  at  a  later  period  perform  anasto- 
mosis. An  artificial  anus  can 
be  made  by  the  method  of 
Bodine  (page  851).  In  most 
eases  in  which  it  seems  neces- 
sary^ to  make  an  artificial  anus 
do  not  open  the  bowel  at 
once,  because  it  may  recover  in 
a  day  or  two,  w^hen  it  can  be 
restored  to  the  belly  ;  or  it  may 
slough    and    form    an    artificial         lSi«' 

•^  (12:.:-: ',  _         V 

anus.        In     such     doubtful     cases        Ficsss—Hemiotomy  in  inguinal  hemia. 

fasten  the  bowel  to  the  belh*- 

wall  with  sutures,  dust  it  with  iodoform,  dress  it  with  hot  anti- 
septic fomentations,  and  await  future  developments.  Gan- 
grenous omentum  requires  ligation  and  resection.  If  the 
bowel  is  fit  to  reduce,  push  it  just  inside  the  ring,  irrigate 
the  parts,  insert  a  drain,  and  suture.  In  most  cases  perform 
a  radical  cure.  In  femoral  hernia  we  can  make  the  incision 
one  inch  internal  to,  and  parallel  with,  the  femoral  vessels, 
and  crossing  the  tumor  and  ligament  (Barker) ;  but  it  is  bet- 
ter to  make  the  incision  of  Fabricius  for  radical  cure.  Divide 
the  constriction  by  cutting  upward  and  a  little  inward.  In 
iiuibilical  hernia  make  a  slighth'-cun-ed  incision  a  little  to 
one  side  of  the  middle  of  the  tumor,  open  the  sac,  separate 
adhesions,  and  divide  the  constriction  by  cutting  upward  or 
downward,  and  sometimes  also  laterally. 


872      DISEASES  AND   INJURIES   OF   THE  ABDOMEN. 

After  an  operation  for  strangulated  hernia  put  the  patient 
to  bed  ;  bend  the  knees  over  a  pillow ;  give  no  food  by  the 
mouth  for  thirty-six  hours  (MacCormac),  only  allowing  the 
patient  bits  of  ice  to  suck  ;  give  nutrient  enemata  containing 
brandy.  Abdominal  pain  and  tenderness  call  for  the  admin- 
istration of  saline  cathartics  and  enemata  containing  turpen- 
tine or  oil  of  rue.  The  enema  rutae  is  a  favorite  preparation 
in  St.  George's  Hospital,  London.  It  is  made  as  follows  : 
Take  sixteen  ounces  of  an  infusion  of  chamomile,  warm  it, 
and  pour  it  upon  3iij  of  confection  of  senna  (Sheild).  If 
there  is  no  abdominal  pain,  and  tenderness,  the  bowels  need 
not  be  disturbed  for  a  few  days;  but  if  at  the  end  of  four  or 
five  days  they  have  not  acted,  give  a  saline  cathartic  and  an 
enema.  Remove  the  drainage-tube  on  the  third  day.  At 
the  end  of  about  three  weeks,  if  a  radical  cure  has  not  been 
attempted,  get  the  patient  up,  first  applying  a  pad  and  a 
spica  bandage  to  the  groin,  and  later  a  truss.  If  a  radical 
cure  has  been  made,  the  patient  should  stay  in  bed  for  one 
month.  A  truss  should  not  be  worn  if  a  radical  cure  has 
been  made. 

Varieties  of  Hernia. — In  direct  ingtwial  Jiernia  the  bowel 
passes  out  through  Hesselbach's  triangle  internal  to  the  deep 
epigastric  artery.  It  enters  the  inguinal  canal  low  down,  and 
passes  outside  the  conjoined  tendon  or  forces  the  conjoined 
tendon  before  it  or  splits  through  the  tendon.  The  neck  of 
the  sac  is  internal  to  the  deep  epigastric  artery.  The  cover- 
ings of  this  hernia,  when  it  passes  external  to  the  conjoined 
tendon,  are  the  same  as  those  of  an  indirect  inguinal  hernia; 
when  a  direct  hernia  pushes  before  it  the  conjoined  tendon, 
its  coverings  are  skin,  superficial  fascia,  intercolumnar  fascia, 
conjoined  tendon,  transversalis  fascia,  subserous  tissue,  and 
peritoneum. 

In  indirect  inginnal  Jiernia  the  bowel  passes  through  the 
internal  abdominal  ring  external  to  Hesselbach's  triangle  and 
external  to  the  deep  epigastric  artery.  It  passes  down  the 
inguinal  canal  and  emerges  from  the  external  ring ;  it  may 
enter  the  scrotum  or  labium  (scrotal  or  labial  hernia),  or  it 
may  not.  The  neck  of  the  sac  is  external  to  the  deep  epi- 
gastric artery.  Its  coverings  are  skin,  superficial  fascia  inter- 
columnar fascia,  cremaster  muscle,  infundibuliform  fascia, 
subserous  tissue,  and  peritoneum. 

Congenital  ingjiinal  Jiernia  is  a  portion  of  bowel  within  an 
unclosed  vaginal  process.  The  bowel  in  congenital  hernia 
has  one  layer  of  peritoneum  in  front  of  it.  The  testicle  is 
posterior  and  below  (Fig.  326).     Always  remember  that  con- 


ABDOMINAL    HER XI A    OR    RUPTURE. 


873 


genital  hernia  may  not  appear  for  several  months  after  birth. 
Congenital  hernia  conceals  or  buries  the  testicle;  acquired 
hernia  does  not.  If  a  \'aginal  process  open  above  and  closed 
below  contains  a  hernia,  the  condition  is  called  hernia  into  the 
funicular  process. 

If  the  funicular  process  is  closed  at  the  abdominal  end 
but  not  below,  a  hernia  in  a  special  sac  may  descend  back  of 
the  vaginal  tunic.  This  condition  is  known  as  infantile 
hernia.  In  infantile  hernia  there  are  three  layers  of  perito- 
neum in  front   of  the  bowel,  the  two  lavers  of  the  vaginal 


Fig.  326. — Congenital 
hernia:  7",  testicle;  F.P, 
funicular  process ;  B, 
bowel. 


Fig.  327. — Infantile  hernia  : 
T,  testicle  ;  T.  V,  tunica  va- 
ginalis; S.S,  sac  ;  B,  bowel. 


Fig.  328. — Encysted  infan- 
tile hernia  :  7~,  testicle;  T.V, 
tunica  vaginalis  (represented 
as  distended)  ;  S.S,  sac  ;  B, 
bowel. 


tunic  and  the  one  layer  of  sac.  The  testicle  is  in  front 
(Fig.  327). 

If  the  tunica  vaginalis  is  closed  above  and  not  below,  and 
a  hernia  pushes  down  the  vaginal  process  and  causes  it  to 
double  on  itself,  the  condition  is  known  as  encysted  infantile 
hernia  (Fig.  328). 

In  femoral  hernia  the  bowel  descends  along  the  femoral 
canal,  and  the  neck  of  the  sac  is  at  the  femoral  ring.  The 
neck  of  a  femoral  rupture  is  alwa}'s  external  to  the  pubic 
spine ;  the  neck  of  an  inguinal  rupture  is  always  internal  to 
the  pubic  spine.  Femoral  hernia  is  never  congenital.  Its 
coverings  are  skin,  superficial  fascia,  cribriform"  fascia,  crural 
sheath,  septum  crurale,  subserous  tissue,  and  peritoneum. 

Uvibilical  hernia  may  be  congenital  (the  \^entral  plates 
having  closed  incompletely),  infantile  (the  cicatrix  of  the 
umbilicus  having  stretched),  or  acquired. 

Ventral  hernia  is  a  protrusion  through  any  part  of  the 
anterior  abdominal  wall  except  at  the  umbilicus  or  abo\e  it. 

Epigastric  hernia  is  a  protrusion  of  peritoneum  in  the  space 


874      DISEASES  AND   INJURIES   OF   THE  ABDOMEN. 

bounded  by  the  ensiform  cartilage,  the  ribs,  and  the  umbili- 
cus. The  sac  of  peritoneum  may  be  empty,  may  contain 
omentum,  or  omentum  and  bowel.  The  stomach  veiy  rarely 
passes  into  the  sac.  The  protrusion  is  usually,  but  not 
invariably,  through  the  linea  alba. 

In  propcritoncal  hernia  the  sac  is  between  the  perito- 
neum and  transversalis  fascia.  This  form  of  hernia  is  some- 
times produced  by  making  taxis  on  an  inguinal  hernia,  when 
the  internal  ring  is  small  or  is  blocked  by  an  undescended 
testicle.  In  properitoneal  inguinal  hernia,  which  is  the  most 
common  form,  there  are  two  sacs  detectable,  one  in  the 
scrotum,  the  other  parallel  with  Poupart's  ligament,  and  as 
one  sac  is  emptied  the  other  distends  (Breiter  of  Zurich). 

Obturator  hernia  passes  through  the  obturator  membrane 
or  the  obturator  canal,  and  is  felt  below  the  horizontal  ramus 
of  the  pubes,  internal  to  the  femoral  vessels. 

Lumbar  hernia  occurs  at  the  edge  of  or  through  the  quad- 
ratus  lumborum  muscle. 

Sciatic  or  gluteal  hernia  passes  through  the  great  sacro- 
sciatic  foramen,  above  or  below  the  pyriformis  muscle. 

In  diaphragmatic  hernia  some  viscera  of  the  abdomen  pass 
through  a  natural  or  accidental  opening  into  the  thorax. 
It  is  most  common  on  the  left  side. 

Pudendal  hernia  protrudes  into  the  lower  part  of  the  labium, 
the  bowel  having  descended  between  the  ischial  ramus  and 
the  vagina. 

Perineal  hernia  presents  in  the  perineum,  between  the  rec- 
tum and  the  prostate  gland  or  between  the  rectum  and  the 
vagina. 

Hernia  into  the  foramen  of  Winsloxv  is  very  rare.  Herniae 
rarely  occur  into  the  retroduodenal  fosses,  the  retroccBcalfosscB, 
and  into  the  intersigmoid fossa. 

Vaginal  hernia  is  associated  with  uterine  prolapse  or  ensues 
upon  destruction  of  the  vaginal  wall. 

Rokintansky's  diverticular  herniae  are  due  to  separa- 
tion of  the  muscular  fibers  of  the  bowel  permitting  the  saccu- 
lation of  mucous  membrane  and  peritoneum.  These  false 
diverticula  may  be  no  larger  than  peas  or  may  be  larger 
than  walnuts,  and  there  may  be  scores  of  them  in  one  patient. 
They  may  produce  no  symptoms,  or  may  lead  to  peritonitis 
or  to  symptoms  of  intestinal  obstruction. 

Hernia  of  the  Bladder. — This  is  a  protrusion  of  a  por- 
tion of  the  bladder-wall  through  a  hernial  opening.  The 
protrusion  may  or  may  not  be  covered  with  peritoneum.^     It 

1  Brunner,  in  Dnitsch  Zeitschr.f.  Chir.,  1S98,  vol.  xlvii. 


EXAMTXATION  OF   THE  RECTUM.  8/5 

is  most  irequenth'  met  with  in  the  inguinal  region.  Brunner 
describes  three  forms  :  I.  Entirely  without  a  peritoneal  cover- 
ing (extraperitoneal) ;  2.  Partly  covered  with  peritoneum  (para- 
peritoneal— the  commonest  form);  3.  Completeh'  covered 
with  peritoneum  (intraperitoneal).  The  bladder  may  consti- 
tute the  hernia,  or  there  ma\-  be  an  ordinar\'  hernia,  and  also 
a  cystocele.  In  an  inguinal  hernia  the  bladder  will  be  internal 
and  somewhat  behind  the  other  constituent  parts  of  the  pro- 
trusion. Hernia  of  the  bladder  is  much  more  common  in 
men  than  in  women. 

A  hernia  of  the  bladder  ma\'  become  strangulated.  In 
some  cases  a  diagnosis  of  hernia  of  the  bladder  can  be  made 
b}'  the  fact  that  the  protrusion  lessens  in  size  when  the  patient 
micturates  and  increases  in  size  as  urine  gathers,  or  when 
the  bladder  is  injected  with  fluid.  The  treatment  should  be 
operative.  When  the  bladder  is  exposed,  it  is  replaced  with 
or  without  resection  of  a  portion. 

XXVIII.     DISEASES  AND  INJURIES  OF  THE  RECTUM 

AND  ANUS. 

Bxatnination  of  the  Rectum. — Whenever  possible, 
have  the  bowels  emptied  before  an  examination  by  the  ad- 
ministration of  a  cathartic  and  the  use  of  an  enema. 

Place  the  patient  on  the  left  side,  with  the  knees  drawn 
up  and  the  pelvis  elevated  (the  left-lateral-prone  position  of 
Sims).  The  anus  is  carefully  inspected,  the  anal  folds 
being  opened  during  the  process.  By  inspection  the  surgeon 
can  notice  the  external  opening  of  a  fistula,  external  piles, 
protruding  internal  piles,  mixed  piles,  pruritus,  discharge 
from  the  rectum,  eczema,  fissure,  tumor,  ulcer,  condylomata,  \"^ 
or  abscess. 

Next,  a  digital  examination  of  the  rectum  is  made.  The 
nail  of  the  index-finger  is  filled  with  soap  ;  the  finger  is  oiled 
and  is  gently  inserted  through  the  sphincter,  the  patient 
being  asked  to  strain  lighth-  while  it  is  passing.  A  digital 
examination  enables  the  surgeon  to  detect  an  ulcer,  a 
polypus,  a  tumor,  a  stricture,  and  to  determine  certain 
points  regarding  the  condition  of  the  prostate  in  the  male 
and  the  uterus  in  the  female. 

Next,  in  some  cases,  the  rectum  must  be  examined  with  a 
speculum.  It  is  not  often  necessary  to  give  ether.  Mathew's 
speculum  (Fig.  329)  is  very  serviceable.  Sims's  duckbill 
speculum  is  a  valuable  instrument.  The  speculum  is 
warmed,  oiled,  and  slowly  introduced.     It  is  first  directed 


8/6   DISEASES  AND  INJURIES   OF  RECTUM  AND  ANUS. 


Fig.  329. — Mathew's  self-retaining  rectal  speculum. 

toward  the  umbilicus,  and  when  it  passes  the  sphincter  its 
direction  is  gradually  altered  until  it  is  toward  the  promon- 


FiG.  330. — Kelly's  rectal  specula. 


tory  of  the  sacrum.  Illumination  is  obtained  by  direct 
sunlight,  or  by  a  forehead  mirror  and  an  electric  light. 
This  examination  will  extend,  confirm,  or  disprove  the  find- 


EXAMIXATIOX  OF   THE   RECTUM. 


^77 


ings  of  the  digital  examination  ;  ulcers,  hemorrhoids,  and 
malignant  growths  can  be  carefulK'  examined,  and  the  con- 
dition of  the  rectal  mucous  membrane  can  be  thoroughly 
investigated. 

In  some  cases   where   a   high   examination   is   necessaiy  j* 
Kelly's  tubes  are  used  (Fig.  330).     It  is  not  always  neces- 
sar)-  to  give  ether.     The  patient  is  placed  in  the  knee-chest 
position   (Fig.   331).      A    tube    containing    an   obturator    is 


Fig.  331. — Examination  of  the  rectum  by  reflected  light  ^Kelly). 

well  greased  with  vaselin.  "  The  buttocks  are  drawn  apart, 
and  the  blunt  end  of  the  obturator  is  laid  on  the  anus,  which 
is  also  coated  with  vaselm.  The  direction  of  the  instrument 
should  be  first  downward  and  forward,  and,  when  the  sphinc- 
ter is  well  passed,  up  under  the  sacral  promontory.  The 
moment  the  speculum  clears  the  sphincter  ani  and  the 
obturator  is  withdrawn  air  rushes  in  audibh'  and  distends 
the  bowel."  The  bowel  being  distended  with  air.  the  mucous 
mem.brane  is  plainly  seen  as  the  tube  is  sloAvly  withdrawn 
and  the   light  is   reflected  into  the  speculum.     The    Kelly 


8/8   DISEASES  AND  IXJURIES   OF  RECTUM  AXD  AXUS. 

tube  must  be  used  with  great  care,  as  harm  may  be  done  by 
It,  and  the  long  tube  should  only  be  used  in  exceptional 
cases. 

If  a  patient  is  placed  in  the  knee-chest  position  and  anesthe- 
tized, the  sphincter  can  be  stretched  by  the  fingers,  and  the 
rectum  will  distend  with  air  and  can  be  easily  examined. 
The  fingers  are  introduced  as  suggested  by  Martin  (Fig.  332), 


Figs.  332,  333. — A  new  and  simple  method  of  proctoscopy  (Thomas  C.  Martin). 

and  the  rectum   becomes   visible   when  they  are   separated 

(FJ.?-  333)- 

Hemorrhoids,  or  Piles. — There  are  three  varieties  of 
varicose  tumors  of  the  rectum,  namely  :  internal,  which  take 
origin  within  the  external  sphincter ;  exte?')ial,  which  take 
ongin  without  the  external  sphincter ;  and  mixed  hemor- 
rhoids, which  are  a  combination  of  the  two. 

External  hemorrhoids  are  covered  with  skin.  Internal 
hemorrhoids  are  covered  with  mucous  membrane.  The 
term  external  hemorrhoids  is  not  strictly  accurate,  as  hemor- 
rhage does  not  occur  in  external  piles,  and  all  external  piles 
are  not  related  to  the  external  hemorrhoidal  veins.  An 
external  pile  may  in\olve  the  veins  or  the  skin.  If  the  veins 
are  involved,  there  may  be  varicosity  of  the  plexus,  a  condi- 
tion due  to  straining,  often  associated  with  internal  piles  and 
productive  of  no  particular  annoyance.  Symptoms  appear 
when  phlebitis  arises ;  phlebitis  causes  thrombus,  and  the 
vein  commonly  ruptures. 


HEMORRHOIDS,    OR   PILES.  879 

External  Hemorrhoids. — When  a  vein  inflames  the  parts 
are  itch)',  painful,  and  swollen,  and  defecation  increases  the 
pain.  When  the  vein  ruptures  a  livid,  soft  enlargement 
appears  near  the  edge  of  the  anus,  accompanied  by  decided 
pain  and  other  evidences  of  inflammation.  These  blood- 
tumors  may  get  well  if  let  alone,  or  they  may  suppurate. 
External  piles  are  apt  to  be  multiple,  and  cause  no  pain 
except  when  inflamed.  When  the  superfluous  tags  of  skin 
around  the  anus  enlarge,  they  give  rise  to  much  pain  and 
inflammation.  These  cutaneous  outgrowths  are  often  spoken 
of  as  a  form  of  external  piles  ;  the\'  are  due  to  some  inflam- 
mation, and  are  frequently  secondary  to  inflammation  of  the 
anus  or  in  the  rectum. 

Syviptoms  and  Treatjuoit. — An  inflammatory  enlargement 
is  detected,  which  is  tender  and  painful.  Pain  is  increased  by 
defecation.  These  piles  do  not  bleed.  In  treating  external 
hemorrhoids  some  surgeons  merely  use  remedies  to  combat 
the  inflammation.  An  old  plan  of  treatment  is  to  incise  the  , 
blood-tumor,  turn  out  theclot,  and  pack  with  a  bit  of  iodo- 
form gauze.  Mathews  freezes  the  part  or  injects  cocain,  1 
catches  up  the  blood-tumor  with  a  volsellum,  excises  the 
tumor  and  the  tabs  of  inflamed  skin,  dusts  the  part  with 
iodoform,  and  dresses  it  with  antiseptic  gauze.  The  bowels 
should  not  be  allowed  to  move  for  two  days.  Never  inject 
external  piles  with  carbolic  acid  ;  it  causes  great  inflamma- 
tion, excessive  pain,  and  is  not  free  from  danger.  If  the 
patient  declines  operation,  order  rest,  a  non-stimulating  diet, 
avoidance  of  tobacco  (Mathews),  the  use  of  saline  purga- 
tives, injections  into  the  rectum  of  cold  water  several  times  a 
day,  sponging  of  the  anus  frequently  with  hot  water,  and  the 
application  of  hot  poultices.  As  the  acute  symptoms  begin 
to  disappear  use  lead-water  and  laudanum  ;  when  they  have 
nearly  subsided  apply  zinc  ointment.  Extract  of  hamamelis 
is  a  valuable  application  to  external  piles. 

Internal  hemorrhoids  are  varicose  tumors  of  the  internal 
hemorrhoidal  plexus,  and  are  found  internal  to  the  external 
sphincter,  just  within  the  anus,  and  they  prolapse  easily. 
They  are  not  simple  varicosities,  but  new  tissue  has  been 
formed,  and  they  are  in  realit}'  \'ascular  tumors.  The}'  are 
covered  with  mucus  membrane.  Capillary  piles  are  small, 
sessile,  with  a  surface  like  a  mulbeny,  and  bleed  freely. 
Children  are  not  very  liable  to  develop  piles  excepting  the 
capillary  form.  Venous  piles  are  the  most  common  variety. 
They  extend  from  just  above  the  anal  margin  of  the  rectum 
for  an  inch  or  more.     They  are  purple  in  color,  soft,  irregular 


8 So   DISEASES  AND   INJURIES    OF  RECTUM  AND   ANUS. 

in  outline,  and  are  usually  multiple.  They  bleed  when  irri- 
tated by  hard  fecal  masses,  but  not  so  easily  as  the  capil- 
lary piles.  Each  pile  is  composed  of  a  varicose  vein,  some 
fibrous  tissue,  and  a  few  arterial  twigs.  Arterial  piles 
are  very  unusual.  They  are  large,  smooth,  pedunculated, 
bleed  easily  and  freely,  and  contain,  besides  a  distended  vein, 
arteries  of  some  size. 

Anything  producing  venous  congestion  in  the  rectum — 
constipation,  diseases  of  the  rectum,  enlargement  of  the 
prostate,  pregnancy,  tumors  of  the  womb,  congestion  of  the 
liver,  cirrhosis  of  the  liver,  certain  diseases  of  the  heart  and 
lungs,  sedentary  occupations,  relaxing  climate,  and  stricture 
of  the  urethra — will  cause  hemorrhoids. 

Symptoms  and  Trcatjnent. — If  there  is  no  bleeding  and  no 
protrusion,  the  piles  give  no  trouble.  The  first  symptom  is 
usually  hemorrhage,  and  rectal  examination  by  the  finger 
and  by  the  speculum  will  make  clear  the  condition.  After  a 
time,  during  defecation,  the  piles  protrude  ;  they  may  reduce 
themselves  when  the  patient  stands  up,  or  it  may  be  neces- 
sary to  push  them  in.  Pain  does  not  exist  in  uncomplicated 
cases,  and  pain  during  or  after  protrusion  means  "  abrasion, 
fissure,  or  ulceration  "  (Mathews).  Palliative  treatment  will 
not  cure,  but  it  will  give  great  comfort.  Some  people  only 
suffer  at  rare  times  when  the  liver  is  congested,  and  such 
subjects  will  not  submit  to  operation.  Remove,  if  possible, 
the  cause  (alcohol,  irritating  foods,  want  of  exercise,  etc.) ; 
restrict  the  diet ;  insist  on  regular  exercise ;  give  a  course  of 
Carlsbad  salt,  and  follow  this  by  the  stomach  use  of  bichlo- 
rid  of  mercury  (gr.  J^  after  each  meal).  Prevent  constipation 
by  a  nightly  dose  of  fluid  extract  of  cascara.  After  each 
movement  wash  the  parts  and  syringe  out  the  rectum  with 
cold  water,  and  dry  outwardly  with  a  soft  rag.  If  the  hemor- 
rhoids prolapse,  after  restoi*ing  them  and  injecting  water, 
insert  a  suppository  containing  gr.  v  of  the  extract  of  ha- 
mamelis,  and  use  another  suppository  at  bedtime.  When 
the  piles  prolapse  and  inflame,  rub  Allingham's  ointment  on 
the  parts  (sij  each  of  ext.  of  conium  and  ext.  of  hyoscyamus, 
oj  of  ext.  of  belladonna,  and  gj  of  cosmolin).  Mathews 
uses  gr.  xij  of  cocain,  5j  of  iodoform,  .^ss  of  ext.  of  opium, 
and  5j  of  cosmolin.  If  the  piles  are  protruding  and  reduc- 
tion cannot  be  effected,  put  the  patient  to  bed,  give  a  hypo- 
dermatic injection  of  morphin,  and  apply  hot  poultices.  If 
reduction  cannot  soon  be  effected,  operation  must  be  re- 
sorted to. 

Operative  Treatment. — Give  a  saline  the  morning  before. 


HEMORRHOIDS,    Ok    PILES. 


88l 


ami  an  enema  the  evening  before  the  operation,  and  wash  out 
the  rectum  well  the  morning  of  the  operation.  In  treating 
by  injection  of  carbolic  acid  the  tumors  are  drawn  out  or  the 
patient  strains  them  out,  an  injection  is  given  by  a  hypoder- 
matic syringe  into  the  center  of  the  pile,  and  as  each  pile 
is  injected  it  is  pushed  into  the  rectum.  The  dose  for  each 
pile  is  lo  drops  of  a  solution  containing  3  parts  of  glycerin, 
3  of  water,  and  i  of  pure  carbolic  acid.  The  injection  is 
rarely  curative,  is  very  painful,  and  may  produce  hemorrhage, 
phlebitis,  pyemia,  stricture,  and  even  death  (W.  T.  Bull). 
The  clamp  and  cautery  may  be  used  in  interno-external  piles. 
The  patient  is  anesthetized,  the  sphincter  is  stretched,  and  the 
pile  is  caught  with  forceps  and  drawn  outside  of  the  sphincter. 
Smith's  clamp  is  applied  with  the  ivory  surface  against  the  mu- 
cous membrane  of  the  bowel, 
the  pile  is  cut  off,  and  the  stump 
is  seared  with  the  Paquelin  cau- 
tery at  a  dull-red  heat.  Excis- 
'^  ,  ion  is  preferred  by  Allingham. 
He     stretches     the     sphincter, 


Fig.    334. — Extirpationof  hemorrhoids  Fig.  335. — 55,  the   lower   circular  incision 

(Esmarch  and  Kowalzig. )  along:  Hilton's  white  line;  M,  tube  of  mucous 

membrane  dissected  from  the  sphincter  ;  B  B, 
dotted  line  showing-  the  place  for  the  upper 
circular  incision  (Edmund  Andrews). 

holds  it  open  with  a  retractor,  catches  up  the  pile,  cuts  it 
off,  and  twists  the  bleeding  vessels.  Some  prefer  to  pass 
a  silk  or  catgut  suture,  cut  off  the  tumor,  and  tie  the  thread 
(Fig.  334).  Whitehead' s  operation  is  suited  to  severe  cases, 
when  the  piles  are  extremely  large  and  form  a  protruding  cir- 
cular mass.  Only  a  surgeon  who  can  master  violent  hemor- 
rhage should  venture  to  perform  it.  The  entire  pile-bearing 
area  of  mucous  membrane  is  dissected  out,  and  the  cut  mar- 
*gin  of  mucous  membrane  is  pulled  down  and  stitched  to  the 
surface.  The  sphincter  may  be  dilated  as  a  preliminar}'- 
measure  (Fig.  335).     This   operation  is  sometimes  followed 

5fi 


882   DISEASES  AND   lAJURIES   OF  RECTUM  AND   ANUS. 

by  disastrous  consequences,  especially  by  fecal  inconti- 
nence.' 

The  application  of  the  ligature  is  the  easiest  and  most 
generally  useful  method.  In  this  operation,  after  anes- 
thetizing, stretch  the  sphincter  and  treat  each  hemorrhoid 
separately.  Catch  a  pile  with  a  pair  of  forceps  or  a  vol- 
sellum,  pull  it  down,  and  cut  a  gutter  through  the  skin- 
margin  if  the  pile  is  of  the  mixed  variety ;  tie  the  small 
piles  without  transfixing,  but  transfix  the  large  piles ;  tie 
with  silk  (coarse  silk  for  the  large  piles,  finer  silk  for  the 
small  piles) ;  cut  off  the  tumor  beyond  the  thread,  and 
cut  the  ligatures  short.  Treat  the  other  piles  in  the  same 
manner.  Irrigate  with  hot  normal  salt  solution,  dust  with 
iodoform,  pack  a  piece  of  iodoform  gauze  into  the  rectum, 
and  apply  a  gauze  pad  and  a  T-bandage.  Give  some 
morphin  to  lock  up  the  bowels,  and  keep  the  patient  on  a 
light  diet  for  three  days,  at  the  end  of  which  time  a  saline 
may  be  given.  Just  before  the  bowels  act  remove  the  dress- 
ings and  give  an  enema  of  warm  water.  After  the  movement 
wash  out  the  rectum  first  with  peroxid  of  hydrogen  and 
next  with  hot  salt  solution,  dust  with  iodoform,  and  apply 
a  gauze  pad  over  the  anus.  Irrigate  daily  until  healing  is 
complete.  After  the  tenth  day  examine  with  a  speculum  to 
see  that  the  ligatures  have  come  away;  if  any  are  found  in 
place,  remove  them. 

Prolapse  of  Anus  and  Rectum. — If  the  mucous  mem- 
brane is  prolapsed,  the  condition  is  called  "  prolapsus  ani ;" 
if  the  entire  thickness  of  the  rectal  wall  is  prolapsed,  it  is 
called  "  prolapsus  recti."  Prolapse,  which  is  apt  to  occur 
from  excessive  straining  at  stool,  is  commonest  in  feeble,  ill- 
nourished  children.  Piles  and  worms  may  be  complicated 
with  prolapse.  Straining  from  phimosis,  stone  in  the  blad- 
der, or  stricture  may  be  causative.  Prolapse  may  be  either 
large  or  small,  but  tends  to  recur  again  and  again,  and 
eventually  the  mucous  membrane  inflames,  ulcerates,  or 
sloughs.     Strangulation  of  the  prolapsed  part  may  occur. 

Treatment. — Palliative  treatment  forbids  straining  at  stool. 
If  prolapse  occurs,  the  protrusion  must  be  bathed  with  cold 
water  and  restored.  Constipation  must  be  prevented  (ene- 
mata  of  water  or  glycerin  may  be  used).  If  a  prolapse  is 
caught  firmly,  place  the  patient  in  the  knee-chest  position, 
wash  the  mass  with  cold  water,  grease  it  with  cosmolin, 
insert  a  finger  into  the  rectum,  and  apply  taxis  around  the 
finger  (Mathews).     If  this  fails,  cover  a  finger  with  a  hand- 

1  Andrews,  in  Mathew'' s  Medical  Quarterly,  Oct.,  1895. 


ULCER    OF   THE    RECTUM. 


883 


kerchief  and  insert  the  wrapped  digit  into  the  rectum  ;  if  this 
proves  futile,  invert  the  patient.  Severe  cases  require  ether 
before  reduction  is  attempted.  After  reduction  apply  a  com- 
press, direct  it  to  be  worn  except  when  at  stool,  and  before 
each  act  of  defecation  give  an  injection  of  cold  water  contain- 
ing an  astringent  (tannin  or  fluid  ext.  hydrastis).  Some  cases 
require  excision  of  the  mucous  membrane,  the  divided  edge 
of  this  membrane  being  stitched  to  the  skin.  In  other  cases 
the  protrusion  is  stroked  with  the  cautery  and  restored.  In 
persistent  cases  of  rectal  prolapse  open  the  abdomen  and 
attach  the  colon  to  the  belly-wall  (colopexy,  Fig.  336). 


Fig.  336. — Joseph  Bryant's  method  of  colopexy:  A,  A,  longitudinal  band,  with  sutures 
passed  behind  it,  including  peritoneal  and  muscular  coats  of  the  intestines,  drawn  forward  ; 
5,  B.  parietal  peritoneum  quilted  to  sides  of  the  intestine,  showing  stitches  ;  C,  old  fecal 
fistula. 


Ulcer  of  the  Rectum. — Ulcers  of  the  rectum  are  divided 
into  the  simple  traumatic,  the  syphilitic,  the  tubercular,  the 
dysenteric,  the  gonorrheal,  and  the  malignant.  The  simple 
ulcer  is  due  to  abrasion  with  fecal  masses  or  a  foreign  body," 
the  abraded  area  ulcerating.  It  may  follow  an  operation 
for  piles  and  also  protracted  labor  (Allingham).  A  simple 
ulceration  is  apt  to  be  single.    The  base  and  edges  of  a  simple 


884   D/SEASES  AND    INJURIES    OF  RECTUM  AND   ANUS. 

ulcer  are  neither  prominent  nor  hard.  Syphilitic  \x\c&t  is  a 
tertiary  lesion  commonest  in  women.  There  are  numerous 
small  ulcers  of  the  mucous  coat  or  submucous  tissue,  but 
little  indurated,  with  sharp-cut  edges  which  are  not  under- 
mined. These  ulcers  fuse  and  constitute  one  large  irregular 
ulcer ;  fibrous  tissue  forms  in  the  wall  of  the  bowel,  indura- 
tion becomes  noticeable,  and  stricture  follows.  There  is 
profuse  discharge,  and  fistulse  are  apt  to  form.  Such  ulcers 
may  be  surrounded  by  nodules  of  a  bluish  color.  The  first  con- 
dition is  often  stricture  due  to  the  formation  of  masses  of  fibrous 
tissue  in  the  rectal  walls,  which  may  ulcerate  (Fournier).  In 
syphilis  there  may  be  a  breaking  down  of  a  huge  gummy 
mass  or  of  multiple  gummata.  It  has  been  proved  by  the 
microscope  that  tubercular  ulceration  may  arise  in  the  rectum. 
Tubercular  ulceration  presents  a  conical  ulcer  with  over- 
hanging edges  and  a  pale-red  base..  There  is  some  mucous 
discharge,  some  tenesmus,  and  a  little  pain.  Dysentery, 
catarrh,  neoplasms,  and  foreign  bodies  produce  ulceration. 
The  symptoms  are  constipation,  burning  pain  during  or  after 
defecation,  straining  at  stool,  and  blood  and  mucus  in  the 
stools.  The  diagnosis  is  made  by  digital  examination  and 
inspection  through  a  speculum. 

Treatment. — In  simple  ulcer  empty  the  bowel  by  the  ad- 
ministration of  a  saline  cathartic,  wash  out  the  rectum  with 
hot  water  after  the  saline  has  acted,  introduce  a  speculum, 
touch  the  ulcer  with  pure  carbolic  acid  or  silver  nitrate  (gr. 
xl  to  sj),  place  the  patient  in  bed,  restrict  him  to  a  liquid  diet, 
and  every  day  inject  iodoform  and  olive  oil  or  insufflate  iodo- 
form into  the  rectum.  If  this  fails,  give  ether,  stretch  the 
sphincter,  incise  the  ulcer  through  its  entire  thickness,  and 
cauterize  with  fuming  nitric  acid,  caring  for  the  case  subse- 
quently as  we  would  a  patient  who  had  had  piles  ligated.  In 
tubercular  ulcer  improve  the  general  health,  send  the  patient 
to  a  genial  climate,  or  at  least  into  the  sunlight  and  fresh  air, 
prevent  constipation,  give  nutritious  food,  especially  fats,  wash 
out  the  rectum  every  day  with  hot  water  and  insufflate  iodo- 
form or  inject  iodoform  emulsion.  Touch  the  ulcer  once  a 
week  with  silver  nitrate  (gr.  x  to  3J).  In  sypliilitic  ulcer  give 
antisyphilitic  treatment  and  treat  the  ulcer  locally  as  is  done 
in  tubercular  ulcer.  Dysenteric  ulcer  requires  injections  of 
hot  water,  the  touching  of  the  ulcer  with  pure  carbolic  acid, 
and  insufflations  of  iodoform. 

Non-cancerous  stricture  of  the  rectum  may  be  con- 
genital or  acquired.  There  are  two  forms  of  acquired  stricture  : 
first,  stricture  due  to  external  pressure ;  second,  stricture  due  to 


NOX-CAXCEROUS   STRICTURE    OF   THE   RECTUM.      885 

primaiy_narro\\ing  of  the  rectal  wall.'  Stricture  due  to  exter- 
nal pressure  is  very  rarely  complete,  and  may  be  caused  by 
bands  of  adhesions  or  a  malignant  growth.  The  second  form 
may  be  produced  by  syi)hilitic  tissue,  ordinary  inflam- 
matory tissue,  cicatrices  after  operations,  sloughing,  tuber- 
cular, syphilitic,  or  dysenteric  ulceration,  rectal  gonorrhea, 
and  traumatism.  The  usual  seat  of  simple  stricture  is 
from  one  inch  to  one  and  a  half  inches  above  the  anus. 
The  deposit  may  be  limited  to  the  submucous  coat  or  all  the 
coats  may  be  involved.  It  is  very  rarely  that  stricture  arises 
as  a  result  of  abrasion  from  fecal  masses  or  foreign  bodies. 
It  may  follow  an  operation  for  piles  if  considerable  tissue  is 
removed,  and  is  an  occasional  sequence  of  Whitehead's  oper- 
ation. Stricture  due  to  dysentery  is  extremely  rare,  and  no 
case  has  ever  been  reported  to  the  U.  S.  Pension  Office 
(Peterson).  The  existence  of  stricture  as  a  result  of  rectal 
gonorrhea  has  not  been  positively  proved.  A  majority  of 
sufferers  from  rectal  stricture  have  labored  under  syphilis,  but 
it  is  not  probable  that  the  lesion  is  syphilitic  in  all  or  even  in 
most  of  them.  The  stricture  may  be  due  to  the  formation  of 
fibrous  tissue,  and  ulceration  may  or  may  not  occur.  It  may 
be  caused  by  the  contraction  and  healing  of  a  large  ulcer. 
There  is  no  doubt  that  tubercular  stricture  does  occur. 
Peterson^  says  a  large  proportion  of  the  victims  of  rectal 
stricture  die  of  phthisis,  and  also  that  one-third  of  so-called 
syphilitic  cases  are  tubercular.  It  may  begin  as  an  ulcer  or 
as  an  infiltration  of  submucous  tissue.  Although  a  syphilitic 
lesion  or  a  tubercular  lesion  may  cause  rectal  stricture,  in 
some  cases  such  lesions  simply  expose  the  tissues  to  infection, 
and  a  benign  rectal  stenosis  results. 

The  symptoms  of  rectal  stricture  are  constipation,  pain 
on  defecation,  straining  at  stool,  the  presence  of  blood  and 
mucus  in  the  stools,  an  open  anus,  and  the  passage  of  stools 
flattened  out  into  ribbons.  The  stricture  is  found  by  the  fin- 
ger or  by  the  bougie.  In  syphilitic  cases,  tubercular  cases, 
and  in  benign  cases  the  fibrous  thickening  is  usually  in  the 
submucous  coat,  and  in  syphilitic  and  tubercular  cases  the 
mucous  membrane  is  apt  to  ulcerate.  Complete  obstruction 
may  come  on,  and  distended  abdomen  with  colic  is  very 
usual.     Cancer  is  described  on  p.  886. 

The  treatment  of  non-cancerous  stricture  is  rest,  non-stim- 
ulating diet,  warm-water  injections,  mild  laxatives,  and  hc)t 
hip-baths.  Cocain  suppositories  may  be  needed.  Any  exist- 
ing disease  is  treated.     Bougies  are  passed  every  other  day. 

^  Reuben  Peterson,  in  Jour.  Amer.  Med.  Assoc.,  Feb.  3,  1900.  *  Ibid. 


886  DISEASES  AND   INJURIES   OF  RECTUM  AND  ANUS. 

Use  a  soft-rubber  bougie,  warmed  and  oiled,  and  introduce  it 
gently.  If  only  the  method  of  gradual  dilatation  is  employed, 
the  patient  must  for  the  remainder  of  his  life  pass  a  bougie 
from  time  to  time.  For  fibrous  strictures  forcible  dilatation 
(divulsion)  by  a  special  instrument  is  employed  or  incision 
is  practised.  Incision  (proctotomy)  may  be  either  external 
or  internal.  In  internal  proctotomy  one  or  more  incisions 
are  made  through  the  stricture  down  to  healthy  tissue, 
the  first  cut  being  in  the  middle  line  posteriorly.  External 
proctotomy,  which  divides  the  sphincters,  is  apt  to  leave 
incontinence  as  a  legacy.  Electrolysis  finds  some  advocates, 
but  on  what  grounds  it  is  difficult  to  see.  In  some  cases  the 
rectum  should  be  removed.  In  incurable  cases  perform  in- 
guinal colostomy. 

Cancer  of  the  rectum  is  the  cancer  of  the  bowel  most 
often  met  with.  It  may  be  primarily  malignant  or  may  arise 
from  an  adenoma.  The  commonest  growths  are  composed 
of  cylindrical  cells,  and  may  be  soft  or  scirrhous.  In  cases 
secondary  to  carcinoma  of  the  anus  ordinary  epithelioma 
arises. 

In  most  rectal  carcinomata  the  cells  present  a  tubular 
arrangement  surrounded  by  a  more  or  less  plentiful  stroma 
of  connective  tissue.  In  soft  tumors  the  connective  tissue 
is  scanty,  in  hard  tumors  it  is  plentiful. 

It  not  unusually  occurs  before  the  thirty-fifth  year,  and  is 
seen  as  early  as  the  twenty-fourth  year.  The  retroperitoneal 
and  inguinal  glands  are  involved  late  or  not  at  all.  Exten- 
sive ulceration  occurs.  If  a  hard  ring  encircles  the  rectum, 
the  lumen  of  the  tube  is  greatly  and  progressively  diminished. 
In  cases  of  diffuse  infiltration  the  lumen  is  not  greatly  les- 
sened. 

Symptoms  and  Treatment. — The  symptovis  of  rectal 
cancer  are  like  those  of  non-malignant  stricture,  except  that 
the  pain  is  greater,  the  hemorrhage  more  severe,  and  constipa- 
tion is  apt  to  alternate  with  diarrhea.  The  finger  and  the 
speculum  make  the  diagnosis.  In  rectal  cancer  metastasis 
occurs  late.  The  most  favorable  cases  for  operation  are 
those  in  which  the  growth  is  small  and  movable.  Accurately 
define  the  extent  of  the  growth  and  endeavor  to  make  out  if 
it  has  invaded  the  cellular  tissue  outside  of  the  rectum,  the 
prostate,  the  bladder,  the  sacrum,  the  uterus,  etc.  Cases  of 
widespread  invasion  should  not  be  subjected  to  radical  oper- 
ation. Palliative  treatvioit  is  as  follows  :  every  day  introduce 
a  tube  through  the  stricture,  wash  out  the  rectum  with  warm 
water,  and  after  washing  inject  emulsion  of  iodoform  (gr.  x  to 


CAXCER    OF   THE   RECTUM. 


887 


5J  of  sweet  oil).  Injections  of  chlorid  of  zinc  (gr.  j  to  sj  of 
water)  lessen  the  foulness  of  the  discharge.  Eventually  co- 
lostomy is  performed.  This  operation  gives  great  comfort  to 
the  patient,  and  allays  pain  and  prolongs  life  by  interceptino- 
the  feces  before  they  reach  the  cancer.  This  operation  is 
employed  for  inoperable  cancer,  for  obstruction,  and  in  cases 
where  metastasis  has  occurred.  Operative  treatment  includes 
one  of  several  procedures.  Internal  proctotomy  does  some 
good.  Excision  of  the  rectum  from  below  (Cripp's  oper- 
ation) is  practised  if  not  more  than  three  inches  require  re- 
moval, if  the  peritoneum  is  not  invaded,  and  if  the  adjacent 
organs  are  free  from  disease.  The  peritoneum  must  not  be 
opened  in  Cripp's  operation.     After  the  growth  is  removed 


Fig.  337. — Different  levels  of  resection  of  the  sacrum  :  KO,  Kocher's  line;  BV,  Kraske's ; 
BH,  Hochenegg-'s  ;  BD,  Bardenheuer's  ;  RS,  Rose's  (,Maas). 

the  divided  rectum  is  pulled  down  and  sutured  to  the  skin. 
Excision  of  the  rectum  after  excising  a  portion  of  the  sacrum 
(Kraske's  operation,  Fig.  337)  is  an  operation  which  permits 
removal  of  the  entire  tube,  portions  of  the  colon,  and  even  of 
adjacent  parts.  The  peritoneum  is  opened  deliberately  in  this 
operation,  and  is  subsequently  closed  with  sutures.  The 
lower  end  of  the  upper  segment  of  bowel  is  fastened  in  the 
wound,  or,  if  colostomy  has  been  previously  performed, 
may  be  closed.  In  some  few  cases  in  which  it  is  not 
necessar}-  to  remo\"e  the  lower  end  of  the  rectum,  the  two 
portions  may  be  anastomosed  after  resection  of  a  part  of  the 
tube.  Kraske's  operation  may  be  done  by  an  osteoplastic 
method,  the  bone  not  being  removed.  It  is  well  to  precede  a 
Kraske  operation  two   weeks  by   an   iliac  colostomy,  which 


DISEASES  AND   INJURIES   OE  RECTUM  AND   ANUS. 

permits  of  cleansing  the  lower  bowel  from  feces  and  lessens 
the  chance  of  severe  wound-infection  and  delayed  healing 
after  the  removal  of  the  rectum.  A  preliminary  colostomy 
may  make  the  operation  of  extirpation  more  difficult  by  fixing 
the  intestine,  and  thus  interfering  with  the  necessary  drawing 
down  of  the  gut  (E.  H.  Taylor).  If  the  growth  is  extensive 
and  the  mesocolon  short,  it  may  be  best  to  perform  a  right 
inguinal  colostomy  ;  but  in  most  cases  left  inguinal  colostomy 
is  preferred  (Gerster).  The  colostomy  remains  open  during 
the  patient's  life,  except  in  those  rare  cases  of  Kraske's  oper- 
ation in  which  the  continuity  of  the  rectum  can  be  re-estab- 
lished after  excision  of  the  growth.  In  such  cases  the  artificial 
anus  is  closed  some  time  after  the  resection  of  the  rectum. 

Foreign  bodies  in  the  rectum,  if  small,  are  extracted 
with  forceps  and  the  fingers  ;  if  large,  ether  must  first  be 
given  and  the  sphincter  must  be  dilated. 

Wounds  of  the  rectum  require  free  drainage,  antiseptic 
irrigation,  and  antiseptic  dressing.  If  the  peritoneum  is 
opened,  laparotomy  must  be  performed,  the  peritoneal  cavity 
irrigated,  the  rectal  wound  sutured,  and  the  abdomen  drained. 

Ischiorectal  abscesses  are  situated  in  the  ischiorectal 
fossa.  They  travel  in  the  line  of  least  resistance,  \\hich  is 
upward,  and  more  often  burst  into  the  bowel  than  externally. 
They  are  caused  by  cold,  by  external  traumatisms,  by  per- 
forations of  the  rectum  by  hard  fecal  masses,  or  by  the 
passage  of  bacteria  into  the  fossa  through  a  fissure,  an  ulcer, 
or  an  ulcerated  pile.  They  may  be  either  acute  or  tubercu- 
lar. The  symptoms  are  the  same  as  those  of  abscess  any- 
where, the  swelling,  however,  being  brawny  and  fluctuation 
being  hard  to  detect.  Pain  in  the  groins  is  often  complained 
of,  and  there  may  be  enlarged  glands  in  these  regions. 

The  treatment  is  instant  incision,  the  cut  radiating  from 
the  anus  like  the  spoke  of  a  wheel.  Incision  is  followed  by 
irrigation  and  packing  with  iodoform  gauze  or  the  insertion 
of  a  drainage-tube. 

Imperforate  Anus. — There  are  two  forms  of  this  con- 
dition. In  one  form  the  rectum  empties  into  the  bladder, 
vagina,  or  urethra.  In  the  other  form  there  is  no  rectal 
opening  either  upon  the  surface  of  the  body  or  in  the  uri- 
nary organs.  The  diagnosis  is  usually  at  once  apparent,  ex- 
cept in  cases  where  the  anus  looks  normal,  when  the  diagnosis 
w-ill  often  not  be  made  until  symptoms  of  obstruction  arise. 

Treatment. — If  the  rectum  bulges  when  the  child  cries, 
open  into  it  with  a  knife  and  keep  the  opening  patent  by 
inserting  a  plug  of  iodoform  gauze.     In  cases  in  which  the 


nSTCLA    IX  AXO. 


889 


rectum  is  more  deeply  seated  a  catheter  is  introduced  into 
the  bladder,  an  incision  is  made  from  the  anus  to  the  coccyx, 
the  rectum  is  sought  for,  and  when  found  is  sewed  to  the 
anus,  and  is  incised.  In  some  cases  Keen  and  others  have 
performed  Kraske's  operation,  pulling  down  the  rectum  to 
the  anal  margin,  sewing  it  there,  and  incising  the  occluded 
anus.  If  the  rectum  cannot  be  found  or  cannot  be  pulled 
down,  an  artificial  anus  must  be  made. 

Fistula  in  ano  is  the  track  of  an  unhealed  abscess.  An 
abscess  in  the  anal  region  is  apt  to  refuse  to  heal  because  of 
the  constant  movement  of  the  parts  (produced  by  respiration, 
coughing,  the  passage  of  gas,  defecation,  etc.).  The  passage 
of  feces  will  keep  a  fistula  open.  If  a  tubercular  ulcer  per- 
forates, a  tubercular  sinus  forms,  and  a  tubercular  sinus  is 
also  apt  to  follow  a  cold  abscess  of  the  ischiorectal  space. 
Fistula  is  often  associated  with  phthisis  pulmonalis,  and  is 
not  unusually  linked  with  piles,  cancer,  or  stricture. 

There  are  three  varieties  of  fistula — the  blind  external 
(Fig.  338,  a),  the  blind  internal  (Fig.  338,  b),  and  the  com- 
plete (Fig.  338,  c).  The  external  opening  is  usualh'  near  the 
anus,  but  may  be  far  away,  and  there  ma\'  be  only  one  path- 


FlG.  33S. — FU.ula  in  ano  :  A,  blind  external ;   B,  blind   internal ;   c,  complete   i  Esmarch  and 

Kowalzig). 


way  or  there  may  be  several  sinuses.  In  a  healthy  indi\"idual 
the  external  orifice  is  small  and  a  mass  of  granulations  sprouts 
from  it.  In  a  tubercular  fistula  the  external  orifice  is  large 
and  irregular,  with  thin  and  undermined  edges,  shows  no 
granulations,  extrudes  small  quantities  of  sanious  pus,  and 
the  skin  about  it  is  purple  and  congested.  In  a  fistula  fol- 
lowing an  anal  abscess  the  internal  opening  is  just  above  the 
anus,  between  the  two  sphincters.  In  fistula  following  an 
ischiorectal  abscess  the  internal  opening  may  be  above  the 
internal  sphincter.  A.  sinus  ma}-  run  up  under  the  mucous 
membrane  from  the  internal  opening.  In  a  horseshoe  fistula 
the  internal  opening  is  usually  upon  the  posterior  wall  of  the 
bowel,  "  and  from  this  a  tract  leads  into  the  ischiorectal 
fossa,  not  on  one  side  only,  but  upon  both.  Therefore  we 
have  one  opening  into  the  bowel  and  one  through  the  skin 


890  DISEASES  AND   INJURIES   OF  RECTUM  AND  ANUS. 

on  either  side."  ^  In  some  cases  of  horseshoe  fistula  there  is 
no  internal  opening ;  in  other  cases  there  are  two  openings. 
In  an  old  fistula  the  track  becomes  fibrous  and  cannot  col- 
lapse. Two  or  more  fistulae  may  exist  in  the  same  patient. 
In  dealing  with  a  fistula  always  determine  if  the  condition  is 
stationary  or  progressive.  The  symptoms  of  a  complete 
fistula  are  the  passage  of  feces  and  gas  through  the  opening 
and  the  flow  of  a  discharge  which  stains  the  clothing.  In  a 
complete  fistula  a  probe  can  be  carried  from  the  external 
opening  into  the  bowel.  After  a  time  incontinence  of  feces 
is  apt  to  come  on,  repeated  attacks  of  inflammation  thicken- 
ing the  rectum  and  destroying  its  sensibility.  From  time  to 
time  the  opening  will  block,  and  new  abscesses  form.  In 
examining  a  fistula  use  Brodie's  probe,  as  its  flat  handle 
enables  one  to  locate  the  direction  the  bent  instrument  has 
taken,  and  its  slender  shaft  will  find  its  way  through  a  very 
small  channel. 

Treatment. — In  treating  a  fistula  cleanse  the  parts,  as 
cleanly  work,  though  it  will  not  prevent  pus,  will  limit  sup- 
puration. The  external  parts  are  washed  with  soap  and 
water.  The  rectum,  which  must  be  empty,  is  irrigated  with 
hot  saline  solution.  Corrosive  sublimate  should  not  be  used 
in  the  rectum,  because  it  is  irritant,  causes  a  flow  of  serum, 
and  hence  lessens  tissue-resistance,  and  is  rendered  inert  as 
an  antiseptic  by  being  converted  into  sulphid  of  mercury. 
Anesthetize  the  patient.  If  operating  upon  a  complete  fistula, 
pass  a  grooved  director  into  the  external  opening,  carry  it 
through  the  sinus,  make  it  enter  the  bowel,  bring  its  point 
out  extej'nally,  and  lift  the  tissues  be- 
tween the  sinus  and  the  surface.  Incise 
the  tissues  (Fig.  339).  Cut  the  sphincter 
at  a  right  angle  to  its  fibers,  and  do  not 
cut  it  more  than  once  at  one  operation. 
Push  the  finger  to  the  depth  of  the  wound, 
to  deterrnine  that  the  sinus  does  not 
^^  ^(1  ""^     ascend    above    the    internal    opening.     If 

\\     \      there    are    two  fistulse,  cut   one  through, 
-=^==^^^^      -I      and  when   one   heals  cut  the   other.      In 
Fig.    339.— Operation     somc  Straight  sinuscs  the  tract  can  be  ex- 

for    fistula   in   ano    (Es-        .•  .     j  j      ^i  ^  j_  i 

march  and  Kowaizig).        tirpatcd    and   the  parts    sutured,  primary 

union    occasionally    resulting.     Look    for 

branching    sinuses,   and  if  any    are  found   slit  them    open. 

Examine  carefully  to  see   if  there  is   a    sinus  beneath    the 

1  Diseases  of  the   Recftim,  Anus,  aiid  Sigmoid  Flexiwe,  by  Joseph   M.  Ma- 
thews. 


PRURITUS   OF   THE  ANUS.  89 1 

mucous  membrane  of  the  bowel,  and  if  such  a  sinus  is  found 
slit  it  up.  Curet  all  sinuses,  and  ii  they  are  very  fibrous  clip 
them  away  with  scissors.  Cut  away  diseased  skin;  irrigate 
with  salt  solution;  pack  with  iodoform  gauze;  and  dress  with 
gauze  and  a  T-bandage.  In  forty-eight  hours  remove  the 
dressings,  spray  with  peroxid  of  hydrogen  and  irrigate  with 
salt  solution,  dust  with  iodoform,  insert  lightly  to  the  depths 
of  the  wound  a  piece  of  iodoform  gauze,  and  reapply  the 
dressings.  Dress  the  wound  thus  every  day  until  healing  is 
almost  complete.  It  is  unnecessary  to  confine  the  bowels 
beyond  forty-eight  hours,  at  which  period,  if  they  have  not 
moved,  an  enema  is  given.  If  the  dressing  at  any  time 
becomes  stained  with  feces,  re-dress  at  once.  Get  the  patient 
out  of  bed  as  soon  as  possible. 

If  a  blind  external  fistula  does  not  heal,  every  sinus  must 
be  incised,  and  thickened  walls  must  be  cut  away  or  scraped 
away. 

In  a  blind  internal  fistula  an  external  incision  is  made  to 
convert  the  case  into  a  complete  fistula,  which  is  then  treated 
as  is  directed  above. 

In  horseshoe  fistula,  more  than  one  operation  may  be 
necessary  in  order  to  avoid  cutting  the  sphincter  muscle 
twice  in  one  operation,  a  proceeding  which  would  probably 
lead  to  fecal  incontinence.  One  side  alone  is  operated  on. 
Sinuses  are  opened  and  scraped,  the  sphincter  is  divided,  the 
angles  and  edges  of  skin  are  trimmed  away,  and  the  wound 
is  packed.  When  the  wound  is  healed,  or  nearly  healed,  the 
other  side  should  be  operated  upon. 

If  fecal  incontinence  results  from  an  operation  for  fistula, 
remove  the  scar-tissue  and  endeavor  to  suture  the  separated 
muscular  fibers.  Should  an  operation  be  undertaken  for 
fistula  if  phthisis  exists  ?  Many  of  the  old  masters  said  no. 
Mathews  sums  up  the  modern  view:  in  incipient  phthisis 
operate ;  in  rapidly  progressive  fistula  operate  whether  cough 
exists  or  not ;  if  much  cough  exists,  do  not  operate  unless 
the  fistula  is  rapidly  progressive ;  in  the  last  stages  of  phthi- 
sis do  not  operate. 

Pruritus  of  the  anus  is  a  symptom,  and  not  a  disease. 
It  may  be  due  to  piles,  fissure,  seat-worms,  eczema,  nerve- 
disturbance,  kidney  disease,  jaundice,  constipation,  inebriety, 
the  opium-habit,  torpid  liver,  dyspepsia,  alcohol,  tea-drinking, 
vesical  calculus,  tobacco-smoking,  urethral  stricture,  uterine 
disease,  diabetes,  ovarian  trouble,  and  mental  disorder.  The 
itching  is  worse  at  night,  and  is  often  of  fearful  intensity. 

Treatment. — Remove  the   cause.      Prevent    constipation. 


892    DISEASES  AXD   INJURIES    OF  RECTUM  AND   ANUS. 

Several  times  a  day  wash  the  parts  with  very  hot  water, 
dry  them,  and  apply  a  mixture  containing  .5j  of  campho- 
phenique  and  5J  of  water  (Mathews).  Kelsey  directs  that 
the  parts  be  cleansed  twice  a  day,  and  after  each  cleansing 
that  the  following  ointment  be  applied :  menthol,  .5j ;  cerat. 
simp.,  sij ;  oil  of  sweet  almonds,  fsj  ;  acid,  carbolic,  .5j  ;  pulvis 
zinc,  oxid.,  sij.  Mathews  commends  the  following  mixture : 
chloral,  3j ;  gum-camphor,  3ss  ;  glycerin  and  water,  each  5J.^ 
In  this  disease  a  "  scarf-skin  "  forms,  which  must  be  made  to 
peel  off  by  the  application  of  iodin,  pure  carbolic  acid,  corro- 
sive sublimate  (grs.  iv  to  3J  of  cosmolin),  calomel  (,5ij  to  5J  of 
cosmolin),  or  campho-phenique.  In  obstinate  cases  paint  the 
parts,  night  and  morning,  with  a  mixture  of  60  gr.  of  alum, 
30  gr.  of  calomel,  and  300  gr.  of  glycerin ;  or  smear  with  an 
ointment  composed  of  \  part  of  oleate  of  cocain,  3  parts  of 
lanolin,  2  parts  of  vaselin,  and  2  parts  of  olive  oil  (Morain). 
In  very  severe  cases  touch  with  a  solution  of  silver  nitrate 
(i  :  10),  employ  the  Paquelin  cautery,  or  resect  the  mucous 
membrane  as  in  Whitehead's  operation  for  hemorrhoids. 

Fissure  of  the  anus  is  an  irritable  ulcer  at  the  anal  ori- 
fice producing  spasm  of  the  sphincter.  Pain  exists  because 
twigs  of  nerves  are  exposed  upon  the  floor  of  the  ulcer. 
Fissure  is  caused  by  constipation  or  traumatism.  The  symp- 
tom is  violent,  burning  pain,  sometimes  beginning  during 
defecation,  but  usually  at  the  end  of  the  act,  and  lasting  for 
some  hours.  Constipation  exists,  and  often  pruritus. 
Examination  discloses  a  fissure,  usually  at  the  posterior 
margin,  running  up  the  bowel  one-quarter  to  one-half  an 
inch.     Piles  often  exist  with  fissure. 

Treatment. — The  palliative  trcaiuient  is  to  prevent  con- 
stipation, to  wash  out  the  rectum  with  cold  water,  and  apply 
an  ointment  made  by  evaporating  .^ij  of  the  juice  of  conium 
to  sij,  and  adding  it  to  3J  of  lanolin  and  gr.  xij  of  persul- 
phate of  iron.  Pure  ichthyol  may  do  good.  In  operative 
treatment  stretch  the  sphincter.  In'  order  to  stretch  the 
sphincter  the  patient  is  anesthetized,  the  surgeon's  thumbs 
are  inserted  into  the  rectum,  and  the  parts  are  stretched 
until  the  thumbs  touch  the  ischia.  After  stretching  the 
sphincter  incise  the  floor  of  the  fissure,  scrape  it  with  a  curet, 
and  touch  with  nitrate  of  silver  stick. 

'  Diseases  of  the  Rectum. 


ANESTHESIA.  893 

XXIX.  ANESTHESIA  AND  ANESTHETICS. 

Anesthesia  is  a  condition  of  insensibility  or  loss  of  feel- 
ing artificially  produced.  An  anesthetic  is  an  agent  which 
produces  insensibility  or  loss  of  feeling.  Anesthetics  are 
divided  into — (i)  Goicral  anesthetics,  as  amylene,  chloroform, 
ethylene  chlorid,  ether,  bromid  of  ethyl,  nitrous  oxid,  and 
bichlorid  of  methylene ;  (2)  Local  anesthetics,  as  alcohol, 
bisulphid  of  carbon,  chlorid  of  ethyl,  carbolic  acid,  ether 
spray,  cocain,  eucain,  ice  and  salt,  rhigolene  spray,  and  ethyl 
chlorid  spray. 

Anesthesia  may  be  induced  by  a  general  anesthetic  to 
abolish  the  usual  pain  of  labor  and  of  surgical  procedures ; 
to  produce  muscular  relaxation  in  tetanus,  herniae,  disloca- 
tions, and  fractures;  and  to  aid  in  diagnosticating  abdominal 
tumors,  joint-diseases,  fractures,  and  malingering. 

Whenever  possible,  prepare  a  patient  for  anesthesia,  and 
prepare  him,  if  the  case  admits  of  it,  during  two  or  more  days. 
Heart  disease  is  not  a  positive  contraindication  to  surgical 
anesthesia.  It  is  quite  true  that  anesthetics  are  dangerous 
in  people  with  fatty  hearts,  but  shock  is  also  dangerous, 
and  the  surgeon  stands  between  the  Scylla  of  anesthesia 
and  the  Charybdis  of  shock.  Gallant  truly  says  that  not 
enough  attention  is  paid  to  the  "  character  of  the  pulse  and 
action  of  the  heart  before  operation,  by  which  to  compare  its 
work  during  anesthesia,  and  after  the  operation  is  over,  and 
this  neglect  leads  to  unnecessary  stimulation  and  overdriving 
a  heart  which  is  doing  its  average  best."^  Always  examine 
the  urine  if  the  nature  of  the  case  allows  time.  If  albumin 
is  found,  operation  is  not  contraindicated ;  but  the  peril  of 
anesthesia  is  greater,  and  certain  dangers  are  to  be  watched 
for  and  guarded  against.  If  much  albumin  is  present,  post- 
pone operation  except  in  emergency  cases.  If  much  sugar 
is  found,  the  danger  is  considerable,  as  diabetic  coma  occa- 
sionally develops.  Empty  the  intestinal  canal  by  purgation. 
It  is  well  to  give  the  bowel  six  to  twelve  hours'  rest  before 
operation.  The  usual  custom  is  to  give  a  saline  cathartic  the 
evening  before  operation  and  an  enema  early  on  the  morning 
of  the  operation.  Of  course,  frequently  the  nature  of  the 
case  or  the  necessity  for  haste  does  not  permit  of  preliminary 
emptying  of  the  intestine  by  the  administration  of  cathartics. 
During  the  twenty-four  hours  preceding  operation  the  food 
should  be  easily  digestible  and  given  in  small  amounts. 
During   the    day  or    so    before    operation    there   is    usually 

^  Medical  Record,  February  2,  1899. 


894  ANESTHESIA   AND  ANESTHETICS. 

impaired  digestion,  and  no  undue  strain  should  be  put  upon 
the  stomach.  In  the  morning  allow  no  breakfast  if  the  opera- 
tion is  to  be  performed  at  an  early  hour ;  but  if  the  patient  is 
very  weak,  order  a  little  brandy  and  beef-tea.  If  the  opera- 
tion is'  to  be  about  noon,  give  a  breakfast  of  beef-tea  and 
toast  or  a  little  consomme ;  never  give  any  food  within  three 
hours  of  the  operation,  but  brandy  is  admissible  if  it  is 
required.  If  the  stomach  is  not  empty  at  the  time  of  opera- 
tion, vomiting  is  almost  inevitable,  and  portions  of  food  may 
enter  the  windpipe  ;  if  the  stomach  contains  no  food,  vomiting 
is  far  less  likely  to  happen,  and  even  if  it  occurs  and  vomited 
matter  should  enter  the  windpipe,  it  may  do  little  harm,  as  it 
consists  chiefly  of  liquid  mucus.  In  cases  of  intestinal 
obstruction  in  which  there  has  been  stercoraceous  vomiting 
there  is  much  danger  that  vomiting  will  occur  during 
anesthetization.  In  some  cases  of  intestinal  obstruction, 
during  the  administration  of  the  anesthetic,  and  during  the 
anesthetic  state,  a  stream  of  stinking  brown  fluid  may  flow 
without  effort  from  the  mouth.  Vomiting  or  regurgitation 
of  stercoraceous  material  is  profuse,  sudden,  and  dangerous. 
It  may  flood  the  bronchial  tubes  during  inspiration  and 
cause  death  by  suffocation.  In  such  a  case  wash  out  the 
stomach  before  giving  the  ether.  If  a  patient  with  intestinal 
obstruction  is  too  weak  to  permit  lavage,  use  only  local 
anesthesia.  Vomiting  while  under  an  anesthetic  is  dangerous 
in  any  case,  because  of  the  great  cardiac  weakness  which 
precedes  and  follows  it.  If  a  patient  sleeps  well  the  night 
before  an  operation,  he  will  probably  take  the  anesthetic 
better  than  if  he  sleeps  poorly.  Effort  should  be  made  to 
obtain  a  night's  sleep.  An  excellent  expedient  is  a  hot 
ammonia  bath,  followed  by  a  rub-down  with  weak  alcohol.^ 
It  may  be  necessary  to  administer  trional  or  bromid.  Before 
giving  the  anesthetic  see  that  artificial  teeth  are  removed 
and  that  the  patient  does  not  have  a  piece  of  candy  or  a 
chew  of  tobacco  in  the  mouth.  Always  have  a  third 
party  present  as  a  witness,  because  in  an  anesthetic  sleep 
vivid  dreams  often  occur,  and  erotic  dreams  in  women  may 
lead  to  damaging  accusations  against  the  surgeon.  Place 
the  patient  recumbent.  The  effort  should  be  to  place  him  in 
as  comfortable  a  position  as  possible  if  this  position  is  con- 
sistent with  operative  necessities.  See  that  the  clothing  is 
loose,  particularly  that  there  is  no  constriction  about  the 
neck  and  abdomen.  Do  not  have  the  head  high  unless  this 
position  is  demanded  by  the  exigencies  of  the  operation.    The 

^  A.  Ernest  Gallant,  Med.  Record,  December  30,  1899. 


ANESTHESIA.  895 

anesthetist  must  have  a  mouth-gag,  a  pair  01  tongue-forceps, 
a  hypodermatic  needle  in  zuorking  order,  and  solutions  of 
strychnin,  atropin,  digitalis,  and  brandy.  It  is  well  to 
have  an  electric  battery  and  a  can  of  oxygen  at  hand.  Acci- 
dents, it  is  true,  are  rare,  but  they  may  happen  at  any  time, 
and  hence  the  surgeon  should  always  be  prepared  for  them. 
Any  danger  which  arises  must  be  met  with  promptness  and 
decision,  or  action  will  be  of  no  avail.  Many  surgeons  give 
a  hypodermatic  injection  of  morphin  a  short  time  before 
operation,  to  steady  the  heart,  prevent  vomiting  during  anes- 
thetization, to  shorten  the  stage  of  excitement,  and  aid  the 
bringing  about  of  insensibility  with  very  little  of  the  anes- 
thetic. There  are,  however,  objections  to  morphin  before 
anesthesia,  and  its  use  should  be  the  exception  and  not  the 
rule.  It  depresses  the  respiration,  lowers  temperature,  and 
thus  increases  operative  shock,  interferes  with  the  pupillary 
phenomena  of  anesthesia,  delays  awakening  from  the  anes- 
thetic sleep,  and  actually  favors  post-anesthetic  vomiting. 
In  some  cases  we  may  anticipate  trouble  from  the  anesthetic. 
Cyanosis  may  occur  in  drunkards;  in  fat,  thick-necked  indi- 
viduals of  the  Major  Bagstock  type,  who  are  short  of  breath 
and  congested  in  appearance;  in  individuals  with  some  disease 
of  the  lungs,  bronchi,  pharynx,  larynx,  or  trachea  (empyema, 
emphysema,  chronic  bronchitis,  croup,  cancer  of  the  larynx, 
etc.) ;  in  individuals  suffering  from  fatty  heart  or  valvular 
incompetence.  Buxton  points  out  that  an  individual  without 
teeth  and  with  stenosis  of  the  nares  is  apt  to  become  cyanotic 
under  an  anesthetic,  because  the  lips  and  pillars  of  the  fauces 
are  drawn  in  like  valves  during  inspiration. 

The  two  favorite  anesthetics  are  ether  and  chloroform. 
Chloroform  is  more  dangerous  than  ether  in  general  cases, 
though  it  is  more  agreeable,  less  irritant  to  the  lungs  and 
kidneys,  and  quicker  in  its  action.  Chloroform  is  a  safer  an- 
esthetic in  warm  than  in  cold  countries.  Recovery  from 
chloroform  is  quicker  and  quieter  than  that  from  ether, 
but  chloroform-vomiting  lasts  longer  than  ether-vomiting. 
Chloroform  may  induce  sudden  and  even  fatal  syncope. 
Hare's  experiments  on  animals  indicate  that  chloroform  may 
kill  by  respiratory  failure  occurring  secondarily  to  failure  of 
the  vasomotor  center ;  but  certain  it  is  that  clinically  the 
danger  of  chloroform  is  paralysis  of  the  heart,  and  this  con- 
dition may  come  on  so  rapidly  that  death  may  occur  almost 
before  an  attempt  can  be  made  to  save  life.  Leonard  Hill 
has  proved  that  most  chloroform-deaths  that  take  place  after 
considerable  of  the  anesthetic  has  been  taken  arise  from  para- 


896  ANESTHESIA   AND  ANESTHETICS. 

lytic  distention  of  the  heart.  Sudden  death,  when  inhalations 
of  chloroform  have  just  commenced,  may  be  due  to  the  irri- 
tant vapor  acting  on  the  nasal  mucous  membrane,  exciting  a 
nasal  reflex  and  powerfully  stimulating  cardiac  inhibition.  If 
ether  kills,  it  does  so  usually  through  the  respiration,  and  not 
the  heart,  and  there  is  generally  time  to  undertake  means  of 
resuscitation,  which  means  are  apt  to  be  successful.  Chloro- 
form is  to  be  preferred  to  ether  in  the  following  cases  :  for 
children  under  ten  years  of  age,  in  whom  ether  causes  a 
great  outflow  of  bronchial  mucus,  which  may  asphyxiate  ;  for 
people  over  sixty,  free  from  advanced  cardiac  disease,  at  which 
age  most  persons  have  some  bronchitis,  and  ether  chokes 
them  up  with  mucus.  Ether  also  irritates  the  kidneys,  which 
at  the  latter  age  are  apt  to  be  weak  or  diseased.  Chloroform 
is  preferred  for  labor  cases,  when  moderate  anesthesia  only  is 
required,  and  for  operations  on  the  mouth  and  nose.  In 
cleft-palate  operations  chloroform  is  usually  preferred,  because 
it  causes  but  little  cough  and  salivary  flow.  In  ligation  of  a 
large  artery  which  is  overlaid  by  a  vein,  ether  exercises  the 
unfortunate  influence  of  greatly  enlarging  the  vein.  Hence 
in  such  a  case  chloroform  makes  the  operation  easier.  In 
goiter  operations  ether  should  not  be  used,  as  it  enlarges 
enormously  the  veins.  Chloroform  is  preferred  for  patients 
with  difficult  respiration  from  any  cause  other  than  heart 
disease,  for  patients  with  kidney "  disease,  and  for  patients 
with  diabetes.  Some  surgeons  do  not  use  ether  in  abdomi- 
nal operations,  because  they  beHeve  it  may  cause  persistent 
oozing  of  blood,  but  this  view  is  not  in  accord  with  the 
author's  experience.  Ether  is  safer  in  patients  with  heart 
disease,  and  is  the  best  and  safest  anesthetic  for  general  use. 
Both  ether  and  chloroform  may  induce  changes  in  the 
blood. ^  In  practically  all  cases  they  produce  a  diminution 
of  hemoglobin  and  leucocytosis.  In  some  cases  they  pro- 
duce alteration  in  the  shape  of  the  corpuscles.  These 
changes  are  especially  marked  in  anemic  blood.  Ether  pro- 
duces distinct  leucocytosis,  probably  toxic  in  origin.  These 
blood-changes  indicate  that  prolonged  anesthesia  may  mili- 
tate against  recovery  from  a  severe  operation.  If  a  patient's 
hemoglobin  is  below  30  per  cent.,  a  general  anesthetic  should 
not  be  given.  During  the  state  of  anesthesia  the  tempera- 
ture drops  from  one  to  three  degrees,  hence  the  patient 
should  be  carefully  covered  during  the  operation.  The  ques- 
tion as  to  the  effect  of  ether  on  the  kidneys  is  much  disputed. 

*  See  the  author  on   the   "  Blood-alterations  of  Ether-anesthesia,"    Medical 
News,  March  2,  1 895. 


ADMIXISTKATIOX  OF  CHLOROFORM.  897 

]\Iost  surgeons  believe  that  it  tends  to  cause  albuminuria  or 
increase  existing  albuminuria.  In  giving  ether  or  chloroform 
the  administrator  must  devote  his  undi\-ided  attention  to  the 
task.  He  must  note  ever}'  symptom,  must  order  or  carr}' 
out  proper  treatment  for  complications,  and  must  keep  the 
operator  informed  as  to  the  necessity  for  haste.  The  anes- 
thetist must  be  a  man  who  has  a  wholesome  respect  for 
ether  and  chloroform,  although  not  afraid  of  them. 

Administration  of  Chloroform. — In  administering 
chloroform  have  at  hand  a  mouth-gag,  tongue-forceps,  a 
clean  towel,  a  hypodermatic  syringe,  solutions  of  str}^chnin, 
atropin,  and  brandy,  an  electric  batter}^,  and  a  can  of  oxygen. 
Use  ov^y  pjire  chloroform  (Squibb's).  The  patient  must  be  re- 
cumbent. No  special  inhaler  is  required,  but  the  drug  may 
be  given  upon  a  thin  towel,  a  napkin,  or  a  piece  of  lint.  The 
inhaler  of  Esmarch  is  ven.-  useful.  In  operations  about 
the  face  Souchon's  instrument  is  ser\'iceable.  Souchon's 
apparatus  is  so  arranged  that  choloform  may  be  given 
through  a  tube  which  is  introduced  through  the  nose,  the 
instrument  being  well  out  of  the  way  of  the  operator. 
Some  surgeons  cocainize  the  nares  before  giving  chloroform, 
so  as  to  prevent  the  dangerous  nasal  reflex  (Rosenberg). 
The  chloroform-vapor  must  be  well  mixed  with  air.  The 
chloroform  is  sprinkled  on  the  fabric  with  a  drop-bottle.  Raise 
the  napkin  well  above  the  mouth,  add  five  drops  of  chloro- 
form, and  tell  the  patient  to  take  deep  and  regular  breaths. 
Add  a  few  more  drops  of  chloroform,  and  when  the  patient 
grows  so  accustomed  to  it  as  not  to  choke,  turn  the  wet  part 
of  the  fabric  toward  the  face  and  place  it  near  the  mouth  ;  do 
not  touch  the  mouth  with  the  wet  lint,  because  it  will  blister. 
It  is  a  good  plan  to  smear  the  lips  with  cosmolin  to  prevent 
blistering.  If  the  drug  is  given  gradually,  struggling  is  not 
usually  violent  or  prolonged.  Never  pour  on  a  large  amount 
at  one  time.  During  the  stage  of  excitement  do  not  suspend 
the  administration  of  chloroform  unless  respiration  becomes 
difficult,  in  which  case  suspend  it  until  the  patient  takes  one 
or  two  respirations.  If  the  patient  struggles,  do  not  push 
the  drug.  He  holds  his  breath  while  struggling,  and  as 
struggling  ceases  takes  full,  deep  breaths.  If  the  inhaler  is 
saturated  with  chloroform,  he  may  inhale  a  dangerous  amount 
during  the  deep  respiration  after  struggling.  Chloroform 
given  in  considerable  amount  when  the  patient  is  breathing 
deeply  from  ether  is  unsafe.  If  chloroform  is  given  subse- 
quent to  anesthetization  by  ether,  it  should  be  given  gradually 
and  well  mixed  with  air.     When  the  patient  becomes  anes- 

57 


898 


ANESTHESIA   AND  ANESTHETICS. 


thetized  give  just  enough  of  the  drug  to  keep  him  so.  Stop 
the  administration  or  give  very  Httle  when  shock  becomes 
evident  or  when  there  is  profuse  hemorrhage.  Chloroform- 
vapor  is  not  inflammable,  hence  it  is  safer  than  ether  when  a 
hot  iron  is  to  be  used  about  the  face  and  when  there  is  a 
lighted  lamp  or  a  stove  in  a  small  room  ;  but  the  presence  of 
flame  decomposes  chloroform  into  irritant  products  of  chlo- 
rin,  which  sometimes  cause  the  patient  and  the  surgeon  to 
cough.  A  combination  of  chloroform  and  oxygen  is  used 
by  some  administrators.  The  patient  who  is  anesthetized 
with  the  mixed  vapor  retains  a  good  color,  but  it  requires  a 
considerable  time  to  render  him  unconscious. 

Administration  of  Kther. — Ether  is  best  given  by 
means   of  an   AUis  inhaler  (Fig.   340).     Have  at  hand  the 

same  drugs  and  appliances  as  when 
chloroform  is  given.  Place  the  dry 
inhaler  over  the  mouth  and  nose, 
let  the  patient  take  several  breaths 
to  gain  confidence,  pour  a  few  drops 
of  ether  into  the  cone,  let  the  patient 
take  several  more  breaths,  and  so  on, 
gradually  increasing  the  amount  of 
ether.  Never  suddenly  add  a  large 
amount  of  the  anesthetic  :  it  causes 
coughing  and  often  vomiting.  When 
the  patient  becomes  thoroughly  an- 
esthetized, diminish  the  amount  of 
ether.  When  bleeding  is  profuse 
or  shock  is  marked,  suspend  the. 
administration  of  ether  or  give  very 
little  of  it.  If  a  hot  iron  is  to  be  used  about  the  face,  re- 
move the  cone  and  fan  away  the  ether  before  bringing  the 
iron  near.  Have  any  light  set  high  up,  as  ether-vapor  is 
heavier  than  air,  and  no  explosion  is  possible  until  it  reaches 
the  level  of  the  flame.  If  the  vapor  takes  fire,  cover  the 
patient's  mouth  and  nose  with  a  towel.  The  use  of  oxygen 
with  ether  delays  the  production  of  unconsciousness. 

Anesthetic  State  from  Bther  or  Chloroform. — The 
inhalation  of  an  anesthetic  produces  irritation  of  the  fauces, 
often  some  cough,  a  profuse  secretion  of  mucus,  acts  of 
swallowing,  dilatation  of  the  pupils,  flushed  face,  and  some- 
times struggling  (especially  in  children  and  in  drunkards). 
If  the  vapor  is  given  at  once  in  concentrated  form,  cough 
w^ill  be  violent  and  will  cause  cyanosis.  If  the  anesthetic  is 
given  carefully,  the  cough  soon  ceases,  the  respirations  become 


Fig.  340. — AUis's   ether-inhaler. 


ANESTHETIC  STATE  FROM  ETHER  OR  CHLOROFORM.    899 

rapid  and  often  convulsive,  the  pulse  becomes  frequent,  and 
the  patient  passes  into  a  condition  of  active  intoxication  with 
preservation  of  sight  and  touch,  loss  of  hearing  and  smell, 
diminution  of  pain  and  sensibility,  and  often  with  illusions  or 
hallucinations.     In  this  stage  the  patient  may  struggle,  and 
while    efforts    are    being    made  to   hold  him    cyanosis  may 
occur.     From  the  stage  of  excitement  just  alluded  to,  many 
subjects  (strong  men   and   drunkards)  pass  into  a  stage  of 
rigidity   in    which    the    muscles    become    rigidly    fixed,    the 
breathing  impeded,  the  respirations  stertorous,  and  the  face 
bluish  and  congested.     Too   rapid  forcing  of  the  anesthetic 
tends  to  cause  rigidity,  and  a  skilled  anesthetist  endeavors 
to  avoid  its  production,  because  it  is  dangerous.     The  next 
stage  is  one  of  insensibility :  the  pupils  are  contracted,  but 
react  to  light.     If  anesthesia  is  deep,  the  contracted  pupils 
will  not  react  to  light ;  if  anesthesia  is  profound,  the  pupils 
dilate,  but  will  not  react  to  light.     The  conjunctival  reflex  is 
gone  ;  the  lids  are  closed  ;  if  the  arm  is  lifted  and  allowed  to 
fall,  it  drops  as  a  dead  weight ;  the  skin  is  cool  and  moist,  and 
often  wet  with  sweat ;  the  respirations  are  easy  and  shallow ; 
the  pulse  is  slow ;  and  there  is  complete  unconsciousness  to 
pain.     The   loss   of  the   conjunctival    reflex  is    the    usually 
accepted  sign  that  the  patient  is  unconscious.     In  a  young 
child  this  reflex  is  soon  exhausted  by  touching  the  eye,  and 
the  sign  is   unreliable.     If  a  baby  is  to  be  anesthetized,  the 
administrator  places  his  finger  in  the  infant's  hand.    The  child 
grasps  the  finger,  and  relaxes  its  grasp  when  unconscious. 
Always  bear  in  mind  that  a  dilated  pupil  reacting  to  light 
and  associated  with  preserved  conjunctival  reflex  means  that 
anesthesia  is  not  complete ;  that  a  contracted  pupil  reacting 
to   light    and    without   conjunctival   reflex   means    moderate 
anesthesia  ;  that  a  contracted  pupil  not  reacting  to  light  and 
without   conjunctival   reflex   means   deep  anesthesia ;   that  a 
dilated  pupil  not  reacting  to  Hght  and  associated  with  lost 
conjunctival  reflex  means  dangerously  profound  anesthesia; 
that  weak  pulse  and  pallor  may  be  due  to  nausea,  but  always 
require  instant  attention  ;  that  vomiting  may  be  due  to  forcing 
strong  vapor  upon  the  patient,  but  that  it  m^y  also  be  due  to 
his  partially  emerging  from  a  state  of  insensibility. 

Watch  the  pulse  carefully  to  see  if  it  becomes  very  weak, 
irregular,  abnormally  slow,  or  abnormally  fast.  Syncope 
may  be  due  to  nausea,  shock,  hemorrhage,  or  the  giving  of 
too  much  of  the  drug.  Watch  the  respiration,  and  do  not 
forget  that  the  chest-walls  and  belly  may  move  when  no  air 
is  entering  the  lungs ;  hence  always  listen  to  the  breathing. 


900  ANESTHESIA  AND  ANESTHETICS. 

Cyanosis  is  a  dusky  or  bluish  discoloration  of  the  skin. 
This  condition  indicates  want  of  oxygen  in  the  blood.  The 
individual  may  have  been  cyanotic  or  predisposed  to 
cyanosis  to  start  with ;  cyanosis  may  be  due  to  posture  ; 
to  cough  early  in  the  administration ;  to  struggling  during 
the  stage  of  excitement  or  to  rigid  fixation  of  the  respiratory 
muscles.  It  may  also  be  due  to  obstruction  of  the  air- 
passages  by  some  foreign  matter,  as  blood  or  vomit,  lodging 
in  the  bronchial  tubes,  windpipe,  larynx,  or  pharynx  ;  falling 
back  of  the  tongue  (swallowing  of  the  tongue) ;  closure  of 
the  epiglottis  ;  or  to  the  glottis  being  pushed  against  the 
pharyngeal  wall  by  bending  the  head  forward.  Some  patients 
with  occluded  nostrils  may  fail  to  get  enough  air  because  of 
closure  of  the  lips.  A  patient  may  appear  to  "forget  to 
breathe."  Shock  is  manifested  by  deadly  pallor,  weak  and 
irregular  pulse,  slow  respiration,  cold  extremities,  and  a 
drenching  sweat.    In  rare  cases  edema  of  the  lungs  occurs. 

Treatment  of  Complications. —  Vomiting  due  to  too 
much  anesthetic  is  corrected  by  giving  a  few  breaths  of  air ; 
vomiting  due  to  incomplete  anesthesia  is  amended  by  giving 
more  of  the  vapor.  When  the  patient  vomits,  hang  the  head 
over  the  edge  of  the  bed,  separate  the  jaws  with  the  gag, 
and  wipe  out  the  vomited  matter,  mucus,  and  saliva.  Shock 
is  treated  by  diminishing  the  amount  of  the  anesthetic  given, 
by  the  hypodermatic  injection  of  brandy,  strychnin,  or  atro- 
pin  (the  last-named  drug  is  very  useful  when  there  is  a 
profuse  sweat),  by  the  administration  of  hot  saline  fluid  by 
the  rectum,  by  surrounding  the  patient  with  hot-water  bottles, 
or  by  wrapping  him  in  hot  blankets,  and  by  lowering  the  head 
of  the  bed.  A  tendency  to  syncope  requires  lowering  of  the 
head  of  the  bed,  suspension  of  the  anesthetic,  and  hypoder- 
matic injection  of  strychnin.  In  extreme  syncope,  which  is 
most  apt  to  occur  from  chloroform,  do  not  wait  for  breathing 
to  cease,  but  suspend  the  anesthetic,  lower  the  head  of  the 
bed,  open  the  mouth  with  the  gag,  catch  the  tongue  and 
make  rhythmical  traction  while  an  assistant  is  making 
slow  artificial  respiration.  If  the  patient  does  not  at  once 
improve,  invert  him  completely,  holding  him  by  the  legs 
and  continuing  artificial  respiration  by  compressing  the 
sternum  (Nelaton).  By  continuing  artificial  respiration  the 
blood  is  urged  on  through  the  heart.  Leonard  Hill  holds 
that  in  the  failure  which  arises  soon  after  administration  of 
chloroform  is  begun  the  trouble  is  due  to  vasomotor 
paralysis  with  starvation  of  the  nerve-centers.  In  such  a 
case    he    applies    abdominal    compression    and    inverts    the 


TREATMENT  OE  COAITLICATIONS.  90I 

patient,  making  artificial  respiration  at  the  same  time.  In 
the  failure  which  occurs  after  considerable  chloroform  has 
been  taken  there  are  paralytic  distention  of  the  heart,  fulness 
of  the  venous  system,  and  loss  of  the  compensations  for  the 
hydrostatic  effects  of  gravity.  In  such  a  condition  empty 
the  distended  heart  of  venous  blood  by  raising  the  patient 
into  an  erect  position;  and  after  a  moment  place  him  recum- 
bent and  make  artificial  respiration.  Give  hypodermatic 
injections  of  ether,  brandy,  strychnin,  or  even  of  ammonia. 
Put  mustard  over  the  heart  and  spine.  Employ  faradism  to 
the  phrenic  nerve  (one  pole  to  the  epigastric  region,  the 
other  to  the  right  side  of  the  root  of  the  neck).  Let  fresh 
air  into  the  room,  put  hot  water-bottles  around  the  legs, 
apply  friction  to  the  extremities,  wrap  the  patient  in  hot 
blankets,  give  an  enema  of  brandy,  and  hold  ammonia  or 
nitrite  of  amyl  to  the  nose. 

"  Forgetting  to  breathe  "  is  met  by  removing  the  inhaler 
and  waiting  a  moment ;  a  breath  will  usually  be  taken  soon  ; 
but  if  it  is  not  taken,  open  the  mouth  and  pull  forward  the 
tongue ;  this  causes  a  reflex  inspiration.  Cyanosis  is  practi- 
cally not  encountered  when  oxygen  is  given  with  ether  or 
chloroform.  Cyanosis,  if  slight,  and  due  to  cough  or  strug- 
gling, is  met  by  removing  the  inhaler  while  the  patient  takes 
a  breath  or  two  of  air.  If  position  is  responsible  for  cyanosis, 
correct  it.  In  empyema,  lying  upon  the  sound  side  may  pro- 
duce it,  and  obstruction  to  breathing  may  be  due  to  bending 
down  the  head.  If  due  to  stenosis  of  the  nares  in  a  person 
without  teeth,  hold  the  lips  apart  with  a  finger. 
,  Dudley  W.  Buxton  points  out  that  duskiness  will  often 
pass  away  if  ether  is  removed,  one  or  two  inhalations  of 
chloroform  given,  and  ether  then  continued.  If  in  any  case 
cyanosis  is  severe  or  grows  worse,  suspend  the  drug,  dash 
cold  water  in  the  face,  force  open  the  jaws,  pull  forward  the 
tongue,  make  artificial  respiration  until  a  breath  is  taken,  and 
then  give  oxygen  for  a  time.  If  these  means  fail,  stretch  the 
sphincter  ani  and  bleed  from  the  external  jugular  vein.  If  a 
breath  is  not  now  taken,  do  tracheotomy.  In  respiratory  or 
heart  failure  forced  artificial  respiration  by  Fell's  method  is  of 
great  value.  In  Fell's  method  a  tracheal  tube  is  inserted,  and 
by  means  of  a  foot-bellows  air  is  forced  into  the  lungs,  after 
first  passing  through  a  warming  chamber.  Instead  of  a  tra- 
cheal tube,  we  may  use  a  face-mask  and  an  intubation-tube. 
"  Swallowing  the  tongue  "  is  corrected  by  pulling  the  tongue 
forward.  If  it  tends  to  recur,  lay  the  head  upon  its  side  or 
keep  the  tongue  anchored    with    forceps.       Closure   of   the 


902  ANESTHESIA   AND   ANESTI/ETICS. 

epiglottis  is  corrected  by  pulling  the  patient's  head  over 
the  edge  of  the  table  and  pushing  strongly  back  upon  his 
forehead.  This  maneuver  lifts  the  hyoid  bone,  and  with  it 
the  epiglottis.  The  epiglottis  can  be  lifted  by  passing  a 
spoon-handle  or  the  index-finger  over  the  dorsum  to  the 
base  of  the  tongue  and  pressing  forward.  If,  in  obstruction 
to  respiration,  the  above  means  fail,  make  artificial  respira- 
tion at  once ;  if  obstruction  continues,  perform  tracheotomy. 

Edema  of  the  lungs  is  treated  by  instant  venesection,  the 
inhalation  of  nitrite  of  amyl,  and  the  administration  of  stimu- 
lants and  nitroglycerin  hypodermatically. 

Artificial  Respiration. — Laborde's  Method. — Place 
the  patient  on  his  back  with  the  head  lower  than  the  body, 
all  the  clothing  loosened,  and  the  jaws  wedged  apart,  and 
wipe  the  mucus  from  the  throat  and  mouth.  Grasp  the 
tongue  with  forceps,  and  once  in  every  four  seconds  pull  it 
quickly  and  strongly  forward  and  then  permit  it  to  go  back. 
It  may  be  necessary  to  keep  up  this  proceeding  for  thirty 
minutes  or  even  more. 

Laborde's  method  should  be  associated  with  "  concentric 
thoracic  and  upward  abdominal  pressure  applied  in  a 
rhythmic  manner  by  two  assistants  at  the  time  of  relaxation 
of  the  tongue."^  Laborde  believes  that  tongue-traction 
causes  contractions  of  the  diaphragm. 

Sylvester's  Method  (Figs.  341,  342). — The  patient  is 
placed  recumbent  with  the  foot  of  the  bed  raised.  The 
surgeon  grasps  the  arms  just  above  the  elbows,  and  draws 
them  outward  and  upward  until  they  are  nearly  perpendic- 
ular ;  they  are  held  perpendicular  for  two  seconds  while  air 
is  entering  the  lungs  ;  the  arms  are  then  lowered  and  pressed 
against  the  sides  of  the  chest  for  two  seconds,  during 
which  time  the  chest  is  emptied  as  in  expiration.  These 
movements  of  elevation  and  depression  are  made  twelve  or 
fifteen  times  a  minute. 

The  Reaction  from  Anesthesia. — After  the  admin- 
istration of  the  anesthetic  has  been  suspended  and  the  oper- 
ation has  been  completed  the  temperature  is  usually  subnor- 
mal. The  patient  must  be  watched  until  consciousness 
returns  If  he  is  left  alone,  a  change  of  posture  may  lead  to 
arrest  of  the  feeble  respiration,  the  assumption  of  the  erect 
position  may  cause  fatal  syncope,  or  mucus  or  vomited 
matter  may  block  the  air-passages  and  cause  suffocation. 
The  best  position  to  place  him  in  is  the  recumbent,  the  head 
being  level  with  the  body  or  somewhat  lower,  and  the  side  of 

*  Joseph  D.  Bryant's  Operative  Surgery. 


AFTER-EFFECTS   OF  ANESTHETICS.  903 

the  face  resting  on  the  pillow.  Shock  is  treated  by  ordinary 
methods.  The  inhalation  of  oxygen  is  of  great  value  in 
rousing  a  patient  from  the  state  of  anesthesia,  and  will  often 
prevent  vomiting.  If  vomiting  occurs,  the  head  should  be 
upon  its  side  or  should  be  hung  over  the  edge  of  the  bed, 
and  after  the  spell  of  vomiting  the  mouth  must  be  wiped 
clear.  The  face  should  be  washed  with  cold  water  and  be 
fanned  rather  actively.     It  is  routine  practice  in  the  Jefferson 


Fig.  341. — Artificial  respiration,  first  movement. 

Medical  College  Hospital  to  administer  vinegar  by  inhalation 
during  the  reaction  from  an  anesthetic.  This  proceeding 
often  prevents  vomiting.  Some  patients  awake  as  from  a 
quiet  sleep;  others  are  noisy,  turbulent,  and  violent.  The 
duration  of  the  period  of  reaction  varies  with  the  anesthetic 
used,  the  amount  given,  and  the  personal  tendencies  of  the 


Fig.  342. — Artificial  respiration,  second  movement. 

patient.  The  patient  must  not  be  allowed  to  sit  up  for  sev- 
eral hours  at  least.  No  food  is  to  be  allowed  for  four  hours. 
After-effects  of  Anesthetics. — Vomiting-. — Vomiting 
may  persist  for  hours,  greatly  exhausting  the  patient  and 
doing  infinite  harm,  it  maybe,  if  the  operation  were  upon  the 
brain  or  an  intra-abdominal  structure.  If  vomiting  continues, 
forbid  food.  Very  hot  water  in  doses  of  a  teaspoonful  should 
be  given  at  frequent  intei-vals.  A  draught  of  hot  water  may 
relieve   the  condition  by  washing    out  the  mucus  from  the 


904 


ANESTHESrA   AND  ANESTHETICS. 


stomach.  Other  remedies  which  may  succeed  are :  hot 
black  coffee,  a  mustard  plaster  over  the  stomach,  fresh  air  in 
the  room,  small  pieces  of  ice  placed  in  the  mouth  and  sucked, 
small  doses  of  iced  champagne,  and  drop  doses  of  a  3  per 
cent,  solution  of  cocain  or  3-drop  doses  of  a  5  per  cent, 
solution  of  eucain.  The  best  remedies  for  persistent  vomit- 
ing are  inhalation  of  vinegar  and  lavage  of  the  stomach. 
Some  persons,  as  Dudley  W.  Buxton  points  out,  suffer  greatly 
from  nausea  although  there  is  little  or  no  vomiting.  In  such 
cases  Buxton  uses  TTLj  of  tincture  of  nux  vomica  in  a  tea- 
spoonful  of  hot  water  ever>'  ten  minutes  until  six  doses  are 
taken.  If  this  plan  fails,  he  gives  drop  doses  of  wine  of 
ipecac  or  minim  doses  of  dilute  hydrocyanic  acid.^ 

Vomiting  from  chloroform  is  usually  more  difficult  to 
check  than  vomiting  from  ether. 

Respiratory  disorders  are  more  often  noted  after  ether 
than  after  chloroform.  Bronchitis  may  follow  or  broncho- 
pneumonia (ether-pneumonia).  Respiratory  difficulties  may 
be  due  to  chilling  the  patient  by  bringing  him  from  a  warm 
operating-room  through  a  cold  hall  and  into  a  cool  bedroom. 
Bronchopneumonia  is  especially  common  in  septic  patients, 
and  may  be  due  in  some  cases  to  aspiration  of  septic 
material  into  the  bronchi  (cases  of  cancer  of  tongue  and 
pharynx,  and  cases  with  stercoraceous  vomiting).  Bronchitis 
and  bronchopneumonia  are  much  more  common  after  ether 
than  after  chloroform.  They  are  treated  by  ordinary  methods. 
If  chloroform  is  given  when  a  gas-light  is  in  the  room,  the 
vapor  is  decomposed  and  certain  highly  irritant  products  are 
inhaled,  which  produce  laryngeal  spasm  and  possibly  bron- 
chitis. The  treatment  is  to  freely  admit  fresh  air  into  the 
room,  and  to  have  the  patient  inhale  oxygen  or  vinegar. 
Ether-pneumonia  must  not  be  confounded  with  post-operative 
bronchopneumonia,  described  by  Wm.  H.  Bennett."  This 
latter  condition,  according  to  Bennett,  may  arise  from  seven  to 
fourteen  days  after  operation  in  robust,  gouty  people,  and  is 
usually  unilateral 

Renal  Complications. — After  the  administration  of  an 
anesthetic,  blood,  albumin,  or  sugar  may  appear  in  the  urine, 
and  the  secretion  may  become  scanty  or  even  be  suppressed. 
It  is  usually  maintained  that  chloroform  is  less  apt  to  irritate 
the  kidneys  than  is  ether,  but  there  has  been  much  dispute 
on  this  point.  If  albumin  is  present  before  anesthetization, 
the  condition  may  be  rendered  worse  when  ether  or  chloro- 
form is  given.     The  truth  of  the  matter  probably  is  that  if 

^  Anesthetics,  by  Dudley  W.  Buxton.  ^  F?-actitioner,  Dec,  1896. 


PRIMARY  ANESTHESIA.  905 

the  kidneys  are  healthy  a  small  or  moderate  amount  of  either 
druo-  is  not  particularly  irritant ;  but  if  the  kidneys  are  dis- 
eased, a  small  amount,  and  even  if  they  are  healthy,  a  large 
amount,  of  either  drug  produces  decided  renal  irritation. 
Chloroform  is  said  to  be  less  irritant  only  because  less  chloro- 
form than  ether  is  given  to  secure  and  maintain  anesthesia. 
Scantiness  or  suppression  of  urine  may  be  due  to  shock 
rather  than  to  ether  or  chloroform.  If  the  urine  becomes 
somewhat  scanty  or  if  albumin  appears  in  it,  give  non-irri- 
tant diuretics,  diaphoretics,  and  cathartics,  and  employ  entero- 
cylsis.  If  the  urine  becomes  very  scanty,  use  hypodermo- 
clysis.  If  post-operative  suppression  arises,  give  intravenous 
infusion  of  hot  saline  fluid. 

Post-anesthetic    Paralysis.— Paralysis  may  arise  during 
anesthesia  as  a  result  of  cerebral  hemorrhage  or  embolism. 

It  sometimes  happens  that  when  a  person  has  come  out 
of  anesthesia  a  palsy  of  some  part  is  found  to  exist^the 
condition  being  peripheral  and  not  central  in  origin.  Such 
palsies  may  be  due  to  pressure  of  an  extremity  upon  a  table- 
edge  or  to  pressure  upon  nerves  by  placing  the  patient  in 
certain  positions.^  Garrigues  points  out  that  when  the  arm 
is  elevated  to  the  side  of  the  head  or  when  it  is  drawn  out 
strongly  from  the  body  the  brachial  plexus  may  be  com- 
pressed by  the  head  of  the  humerus  (Braun).  When  the 
arm  is  in  external  rotation  and  is  drawn  backward  and  out- 
ward the  median  nerve  is  stretched,  and  when  the  forearm  is 
flexed  and  supinated  the  ulnar  nerve  is  stretched  (Braun,  quoted 
by  Garrigues).  Garrigues  insists  that  in  most  cases  the 
brachial  plexus  is  squeezed  betw^een  the  collar-bone  and  first 
rib,  and  it  is  particularly  apt  to  be  squeezed  when  it  is  stretched 
by'  the  head  being  drawn  to  the  opposite  side  or  being 
allowed  to  fall  back.^ 

Post-anesthetic  paralysis  is  most  common  in  the  arm, 
but  may  occur  in  the  leg  or  face.  The  prognosis  is  good  as 
a  rule.     The  treatment  is  that  of  any  pressure-palsy. 

Primary  Anesthesia. — Instruct  the  patient  to  count 
aloud  and  hold  one  arm  above  his  head.  Give  the  ether 
rapidly.  In  a  short  time  he  becomes  mixed  in  his  count 
and  his  arm  sways  or  drops  to  the  side.  There  is  now  a 
period  of  insensibility  to  pain  lasting  only  about  half  a  min- 
ute, and  during  this  period  a  minor  operation  can  be  per- 
formed. The  patient  quickly  reacts  from  primary  anesthesia 
without  vomiting  (Packard). 

1  H.  T-  Garrigues,  in  Amer.  Joiirn.  Med.  Sciences,  Jan.,  1897. 
=*  Artier.  Journ.  Med.  Sciences,  Jan.,  1897. 


906  ANESTHESIA   AND  ANESTHETICS. 

A.  C.  1^4.  Mixture. — This  mixture  is  often  valuable  in 
cases  in  which  ether  cannot  be  given.  It  is  composed  of 
I  part  of  alcohol,  2  parts  of  chloroform,  and  3  parts  of  ether. 
Its  action  is  supposed  to  be  between  that  of  chloroform  and 
ether.  The  objection  to  the  A.  C.  E.  mixture,  as  to  any 
mixture,  is  that  the  materials  do  not  evaporate  in  the  ratio 
in  which  they  are  mixed,  hence  an  uncertain  amount  of 
chloroform  vapor  is  being  inhaled  (Buxton).  This  mixture 
can  be  given  in  a  Junker  or  an  Allis  inhaler.  Plenty  of 
air  must  be  given  with  it.  The  anesthetic  acts  similarly 
to  chloroform. 

Kthyl  bromid  is  sometimes  used  for  short  operations. 
The  unconsciousness  is  obtained  in  one-half  minute  and  is 
rapidly  recovered  from,  and  there  is  no  after-sickness.  The 
unconsciousness  lasts  about  three  minutes.  Three  drachms 
are  given  to  a  child,  and  six  drachms  to  an  adult.  A  towel 
is  put  over  the  face,  and  the  entire  amount  to  be  given  is 
poured  on  at  once,  and  as  soon  as  the  patient  is  unconscious 
the  towel  is  taken  away  and  no  more  of  the  drug  is  given 
(Cumston).  Cases  have  been  reported  in  which  sudden 
death  has  followed  the  administration  of  this  drug,  and  it 
should  not  be  given  if  there  is  disease  of  the  heart,  lungs, 
or  kidneys.^ 

Schleich  has  recently  introduced  a  new  anesthetic 
agent  which  he  claims  is  safer  than  chloroform.  This  sur- 
geon maintains  that  a  material  is  safe  as  an  anesthetic  only 
when  almost  all  of  the  amount  taken  in  at  an  inspiration  is 
expelled  on  expiration.  The  anesthetic  is  unsafe  in  direct 
proportion  to  the  amount  absorbed ;  and  the  lower  the 
boiling-point  of  an  anesthetic  the  less  is  absorbed ;  hence 
an  anesthetic  agent,  to  be  safe,  should  have  a  low  boiling- 
point.  Schleich  makes  three  solutions.  The  first  contains 
(by  volume)  \\  oz.  of  chloroform,  \  oz.  of  petroleum  ether, 
and  6  oz.  of  sulphuric  ether.  The  second  contains  \\  oz. 
of  chloroform,  \  oz.  of  petroleum  ether,  and  5  oz.  of  sul- 
phuric ether.  The  third  contains  i  oz.  of  chloroform,  \  oz. 
of  petroleum  ether,  and  2\  oz.  of  sulphuric  ether.  The 
anesthetic  can  be  given  on  an  Esmarch  inhaler,  an  Allis 
inhaler,  or  a  towel.  The  anesthetic  state  is  quiet,  reaction 
is  rapid,  and  vomiting  occurs  in  but  half  the  cases.  The 
superiority  of  this  new  anesthetic  has  not  been  proved.  It 
sometimes  causes  dangerous  symptoms,  and  has  produced 
death.  Garrigues,  who  formerly  approved  of  it,  has  aban- 
doned it.     It  will  certainly  not  displace  ether  or  chloroform. 

^  See  Cumston,  in  Boston  Med.  and  Surg.  Journ.,  Dec.  20,  1894. 


NITROUS-OXID    GAS.  9^7 

NitroUS-Oxid  gas  may  be  used  to  obtain  anesthesia 
for  brief  operations.  This  gas  is  stored  in  steel  cyHnders, 
in  which  it  is  hquefied.  The  gas  is  passed  into  a  rubber  bag, 
and  is  given  to  the  patient  by  means  of  a  tube  and  a  mouth- 
mask,  a  wedge  being  placed  between  the  patient's  molar 
teeth,'  and  the  nostrils  being  closed  by  the  anesthetist's 
fingers.  The  wedge  must  be  held  by  a  string,  so  that  it 
cannot  be  swallowed.  The  patient  becomes  unconscious  in 
about  one  minute,  and  we  know  the  patient  is  anesthetized 
by  the  stertor  and  cyanosis  and  the  insensitiveness  of  the 
conjunctiva.  Watch  the  pulse,  and  if  it  flags  at  once  sus- 
pend the  administration.  The  phenomena  are  asphyxial 
(stertorous  respiration,  cyanosis,  and  even  convulsions,  dila- 
tation of  the  pupils,  rapid'ity  of  the  heart,  and  swelling  of  the 
tongue).'  It  is  sometimes  useful  to  give  nitrous  oxid  first 
and  follow  this  with  ether.  If  this  method  is  employed  a 
small  amount  of  nitrous  oxid  is  given,  and  the  ether  is  grad- 
ually added.  It  is  dangerous  to  give  a  full  dose  of  nitrous 
oxid  and  then  suddenly  give  a  quantity  of  ether  (Hewitt). 
For  children  and  women  the  method  is  of  great  service,  but 
it  should  not  be  used  for  muscular  men  or  stout  men  of 
middle  age  or  over.^  By  this  method  the  patient  is  anes- 
thetized rapidly  and  pleasantly  with  the  nitrous  oxid,  and 
the  anesthesia  is  maintained  by  the  ether. 

It  used  to  be  thought  that  nitrous  oxid  necessarily  pro- 
duces cyanosis,  because  the  gas  can  only  cause  anesthesia 
by  partially  asphyxiating  the  patient.  We  know  this  is 
untrue,  because  if  nitrous  oxid  is  mixed  with  oxygen  or 
atmospheric  air  anesthesia  is  obtained  without  cyanosis. 
Nitrous  oxid  is  a  genuine  anesthetic  agent.  If  a  prolonged 
administration  of  nitrous  oxid  is  desired,  pure  nitrous  oxid 
can  be  given,  a  breath  of  fresh  air  being  allowed  from  time 
to  time.  By  this  method  Preston  has  anesthetized  many 
patients,  the  duration  of  the  anesthesia  being  from  ten  to  fifty 
minutes.  A  better  plan  is  to  give  nitrous  oxid  and  oxygen. 
Hewitt  formulates  the  following  views  as  to  the  use  of  oxy- 
gen and  nitrous  oxid  :  ^ 

"  In  order  to  obtain  the  best  form  of  anesthesia  oxygen 
should  be  administered  with  nitrous  oxid  by  means  of  a 
regulating  apparatus,  the  percentage  of  the  former  gas  being 
progressively  increased  from  2  or  3  per  cent,  at  the  com- 
mencement of  the  administration  to  7,  8,  9,  or   10  per  cent. 

1  See  Hewitt,  Brit.  Med.  Journ.,  Feb.  18,  1899. 
■■'  Hewitt,  in  Lancet,  Feb.  19,  1898. 
3  Brit.  Med.  Journ.,  Feb.  18,  1899. 


908  ANESTHESIA   AND  ANESTHETICS. 

according  to  the  circumstances  of  the  case.  The  longer  the 
administration  lasts  the  greater  may  be  the  percentage  of 
oxygen  admitted. 

"  The  next  best  results  to  those  obtainable  by  means  of 
a  regulating  apparatus  for  nitrous  oxid  and  oxygen  are  to 
be  secured  by  administering  certain  constant  mixtures  of 
these  two  gases.  Mixtures  containing  5,  6,  or  7  per  cent, 
of  oxygen  are  best  for  adult  males ;  and  mixtures  containing 
7,  8,  or  9  per  cent,  are  best  for  females  and  children.  The 
next  best  results  to  those  last  mentioned  are  to  be  obtained 
by  means  of  mixtures  of  nitrous  oxid  and  air,  from  14  to  18 
per  cent,  of  the  latter  being  advisable  in  anesthetizing  men, 
and  from  18  to  22  per  cent,  in  anesthetizing  women  and 
children." 

I/OCal  Anesthesia. — Freezing-  with  Ice  and  Salt. — 
Take  one-quarter  of  a  pound  of  ice,  wrap  it  in  a  towel,  and 
break  it  into  fine  bits;  add  one-eighth  of  a  pound  of  salt; 
then  place  the  mixture  in  a  gauze  bag  and  lay  it  upon  the 
part.  The  surface  becomes  pallid  and  numb,  and  in  about  fif- 
teen minutes  decidedly  analgesic.  A  spray  of  rhigolene  freezes 
a  part  in  about  ten  seconds.  It  is  highly  inflammable.  Etlier- 
spray  anesthesia  was  suggested  by  Benjamin  Ward  Rich- 
ardson. Chlorid  of  ethyl  comes  in  glass  tubes.  Remove  the 
cap  from  the  tip  of  the  tube  and  hold  the  bulb  in  the  palm  : 
the  warmth  of  the  hand  causes  the  fluid  to  spray  out.  Hold 
the  tube  some  little  distance  from  the  part  and  let  the  fine 
spray  strike  the  surface.  The  skin  blanches  and  whitens,  and 
is  ready  for  the  operation  in  about  thirty  seconds. 

Cocain  Hydrochlorate. — Always  bear  in  mind  that 
cocain  is  sometimes  a  decidedly  dangerous  agent.  There 
are  on  record  fourteen  deaths  from  cocain  (Reclus).  The 
urethra  is  a  particularly  dangerous  region,  and  so  is  the 
face.  Never  use  over  two-thirds  of  a  grain  upon  a  mucous 
surface,  and  never  inject  hypodermatically  more  than  one- 
third  of  a  grain,  and  be  sure  never  to  inject  the  drug  into 
a  vein.  Mild  cases  of  cocain-poisoning  are  characterized 
by  great  tremor,  restlessness,  pallor,  dry  mouth,  talkative- 
ness, and  weak  pulse.  In  severe  cases  there  is  syncope  or 
delirium.  Death  may  arise  from  paralysis  or  from  fixation 
of  the  respiratory  muscles  (Mosso).  Cases  with  a  tendency 
to  respiratory  failure  require  the  hypodermatic  injection 
of  strychnin.  In  cases  with  tetanic  rigidity  of  muscles 
give  enemata  of  chloral,  hypodermatic  injections  of  nitro- 
glycerin, or  inhalations  of  the  nitrite  of  amyl.  In  cases 
marked  by  delirium,  if  the  circulation  is  good,  give  chloral 


LOCAL   AXESTIIESIA.  909 

or  hyoscin.  In  any  case  giv^e  stimulants,  employ  a  catheter, 
and  favor  diuresis.  Cocain-poisoning  is  al\va\'s  followed  by 
a  wakeful  night.  Cocain  should  not  be  used  if  the  kidneys 
are  inefficient.  In  using  cocain  try  to  prevent  poisoning. 
Because  of  the  dangers  inherent  in  cocain,  have  the  patient 
recumbent.  One  minute  before  giving  the  cocain  admin- 
ister one  drop  of  a  I  per  cent,  alcoholic  solution  of  tri- 
nitrin,  repeating  the  dose  once  or  twice  during  the  oper- 
ation. In  operating  on  a  finger,  after  making  the  part 
anemic,  tie  a  tube  around  the  root  of  the  digit  before  inject- 
ing cocain,  and  after  the  operation  gradually  loosen  the  tube. 
A  hot  solution  of  cocain  is  more  efficient  than  a  cold  solu- 
tion (T.  Costa);  hence  hot  solutions  can  be  used  in  much 
less  strength  and  are  safer.  The  method  of  injection  is  as  fol- 
lows :  A  sharp  needle  is  held  at  an  angle  of  fort}--five  degrees 
to  the  surface,  and  is  pushed  into  the  Malpighian  layer.  One 
or  two  minims  of  a  2  per  cent,  solution  are  forced  into  the 
Malpighian  layer,  and  a  whitened  elevation  forms.  The 
needle  is  withdrawn,  at  the  margin  of  the  wheal  is  reinserted, 
and  more  fluid  is  introduced,  and  so  on  until  the  region  to 
be  operated  upon  has  been  injected.  After  waiting  five 
minutes  the  operation  is  begun.  If,  after  cutting  the  skin, 
it  is  necessar}'  to  cut  the  subcutaneous  tissue,  pour  a  iow 
drops  of  a  i  per  cent,  solution  into  the  wound  from  time  to 
time.  After  the  completion  of  the  operation,  if  a  rubber 
band  were  used,  it  is  loosened  for  a  few  seconds,  tightened 
for  a  few  minutes,  again  loosened  and  readjusted,  and  so  on 
several  times  (Wyeth).  In  this  wa}'  only  a  small  quantity 
of  cocain  is  admitted  into  the  circulation  at  one  time,  and 
toxic  symptoms  are  thus  prevented.  For  operations  upon 
the  eye  a  i  to  4  per  cent,  solution  is  instilled ;  a  drop  of 
fluid  is  instilled  ever}'  ten  minutes  until  three  drops  have  been 
given.  Over  f  of  a  grain  should  not  be  painted  upon  a 
mucous  membrane.  Rarely  use  o\'er  a  10  per  cent,  solution 
on  mucous  membranes,  although  in  laryngeal  operations  a 
20  per  cent,  solution  may  be  required.  For  the  nasal 
mucous  membrane  a  bit  of  wool  soaked  in  a  5  per  cent, 
solution  is  inserted  or  a  spray  of  4  per  cent,  solution  is 
thrown  from  an  atomizer  into  the  nostrils.  In  the  rectum, 
vulva,  vagina,  and  uterus  use  a  5  per  cent,  solution  ;  in  the 
urethra  a  4  per  cent,  solution,  and  in  the  bladder  a  2  per 
cent,  solution. 

Cocainization  of  a  Nerve-trunk. — Krogius  has  pointed 
out  that  if  cocain  is  injected  into  the  tissue  about  a  nerve- 
trunk   anesthesia   will   follow  in   the   area   supplied   by   the 


9IO  ANESTHESIA    AND   ANESTHETICS. 

nerve.  The  anesthesia  will  be  produced  in  five  minutes, 
and  will  last  fifteen  minutes.  If  cocain  is  injected  about  the 
root  of  the  finger,  all  of  the  tissues  of  the  digit  will  become 
insensitive.  Injection  over  both  supraorbital  notches  ren- 
ders the  middle  of  the  forehead  insensitive.  Injection  over 
the  ulnar  nerve  causes  complete  anesthesia  of  its  trajectory. 
This  plan  is  extensively  used  in  Helsingfors. 

Eucain  hydrochlorate  is  far  safer  than  cocain,  and  in  most 
cases  is  to  be  preferred  to  it.  Eucain  is  employed.  It  is 
injected  in  the  strength  of  from  2  to  5  per  cent.  It  can  be 
boiled  without  destroying  its  properties,  and  hence  can  be 
readily  rendered  sterile.  It  occasionally,  though  rarely, 
happens  that  the  injection  of  eucain  causes  sloughing,  espe- 
cially at  the  extremities,  in  fatty  tissue,  in  tendon-sheaths, 
and  in  bursse.     It  can  be  used  on  mucous  membranes. 

Infiltration-anesthesia  was  devised  by  Schleich  of  Leip- 
sic,  who  was  dissatisfied  with  cocain,  because  it  is  not  safe 
and  sometimes  fails  to  produce  satisfactory  anesthesia,  owing 
to  want  of  thorough  diffusion.  He  found  that  salt  solution 
(0.2  per  cent),  if  injected  into  uninflamed  parts,  produced 
anesthesia.  To  obtain  this  anesthesia  the  part  must  be  dis- 
tended by  wide  infiltration.  If  minute  quantities  of  cocain, 
morphin,  and  carbolic  acid  are  added  to  the  solution,  the 
anesthesia  becomes  more  thorough  and  more  prolonged, 
and  can  be  obtained  even  in  inflamed  areas. 

Schleich  uses  three  solutions  : 

No.  I,  a  strong  solution,  which  is  used  in  inflamed  areas  : 
cocain  hydrochlorate,  gr.  iij  ;  morphin  hydrochlorate,  gr.  f ; 
sodium  chlorid,  gr.  iij  ;  distilled  sterile  water,  siijf;  phenol 
(5  per  cent.),  2  drops. 

No.  2,  a  medium  solution,  which  is  employed  in  most 
cases  :  cocain  hydrochlorate,  gr.  iss  ;  morphin  hydrochlorate, 
gr.  |- ;  sodium  chlorid,  gr.  iij ;  distilled  sterile  water,  5iij|- ; 
phenol  (5   per  cent.),  2  drops. 

No.  3  is  the  weak  solution  used  to  infiltrate  extensive 
areas  :  cocain  hydrochlorate,  gr.  \ ;  morphin  hydrochlorate, 
gr.  |- ;  sodium  chlorid,  gr.  iij  ;  distilled  sterile  water  .oiij| ; 
phenol  (5  per  cent.),  2  drops. 

The  injections  are  begun  in  the  skin,  not  under  it  (Fig. 
343),  and  are  made  one  after  another  until  the  area  to  be 
operated  upon  is  surrounded  above,  below,  and  on  all  sides 
with  Schleich's  solution.  This  infiltration  can  be  made  pain- 
lessly by  touching  with  pure  carbolic  acid  the  point  where 
the  needle  is  to  be  inserted,  or  by  freezing  this  area  with 
ethyl  chlorid.     When  deeper  tissues  are  reached  they  are 


BURA'S  AXD   SCALDS.  9II 

infiltrated  before  incising  them.  If  a  nerve  comes  in  sight, 
touch  it  with  a  drop  of  pure  carboh'c  acid  (Lund).  Van 
Hook  says  that  the  anesthesia  obtained  by  this  method 
is  due  to  artificial  ischemia,  pressure  upon  the  tissues,  the 


'^'S^'^i^iir  /} 


Fig.  343. — The  syringe-point  slops  at  the  papillary  layer,  and  the   fluid   lodges  in  the  skin 
itself  l,Van  Hook). 

direct  action  of  the  drugs,  and  the  lowered  temperature.^ 
The  method  is  very  efficient,  and  can  be  used  for  operations 
of  considerable  magnitude. 

Cocainization  of  the  Spinal  Cord. — Bier  has  produced 
complete  anesthesia  of  the  entire  body  except  the  head  by 
the  injection  of  a  small  amount  of  0.5  per  cent,  or  i  per  cent, 
solution  of  cocain  into  the  subdural  space  of  the  cord.  The 
needle  is  inserted  as  in  lumbar  puncture,  care  being  taken 
to  prevent  the  escape  of  cerebrospinal  fluid.  The  anesthe- 
sia begins  in  five  minutes,  and  lasts  for  forty-five  minutes. 
In  this  condition  surgical  operations  can  be  performed  with- 
out causing  pain.  Among  the  operations  which  have  been 
performed  are  resection  of  the  knee,  resection  of  ankle,  os- 
teotomy (Bier) ;  amputation  of  the  leg  (Lower) ;  hyster- 
ectomy (Tuffier).  This  method  is  usually  followed  by 
vomiting  and  headache ;  its  safety  has  not  been  determined, 
and  the  real  value  of  the  method  is  as  yet  uncertain. 

XXX.     BURNS  AND  SCALDS. 

Burns  and  scalds  are  injuries  due  to  the  action  of  caloric. 
Scalds  are  due  to  heated  fluids  or  vapors.  There  is  no  true 
pathological  difference  between  burns  and  scalds.  Dupuy- 
tren  classifies  burns  into  six  degrees  as  follows:  (i)  charac- 
terized by  eiythema ;  (2)  characterized  by  dermatitis  with 
the  formation  of  vesicles ;  (3)  characterized  by  partial  de- 
struction of  the  skin,  which  structure  is  not,  however,  en- 
tirely burnt    through  ;    (4)  characterized  by  destruction  of 

1  Med.  News,  Nov.  16,  1895. 


912  BURNS  AND   SCALDS. 

the  skin  to  the  subcutaneous  tissue;  (5)  characterized  by- 
destruction  of  all  superficial  structures  and  of  part  of  the 
muscular  layer;  (6)  characterized  by  "carbonization"  of  the 
whole  thickness  of  the  muscles. 

The  symptoms  of  a  severe  burn  are  local  and  constitu- 
tional. Local  symptoms  are  pain  and  inflammation,  which 
vary  in  nature,  in  intensity,  or  in  degree  according  to  the 
extent  of  tissue-damage.  Constitutional  symptoms  are  very 
weak  pulse,  shallow  respiration,  and  subnormal  tempera- 
ture,— in  other  words,  the  condition  of  shock  exists.  The 
patient  may  die  without  reacting  from  shock,  but  in  most 
cases  there  is  reaction,  followed  by  a  severe  reactionary 
fever,  with  a  strong  tendency  to  congestion  of  internal  parts. 
During  the  existence  of  fever  there  may  be  vomiting,  diar- 
rhea, hemoglobinuria,  and  enlargement  of  the  liver,  spleen,, 
lymph-glands,  and  tonsils.  If  over  two-thirds  of  the  body 
surface  is  badly  burnt,  death  will  certainly  occur,  and  proba- 
bly within  two  days.  Death  after  severe  burns  is  positively 
not  due  to  loss  of  body-heat  in  the  burnt  area,  nor  to  auto- 
intoxication with  retained  body-secretions.  High  tempera- 
ture produces  blood-changes, — viz.,  disintegration  of  red 
corpuscles.  Thrombosis  may  occur,  and  irritation  of  the 
kidneys  and  other  organs  is  produced  by  "  products  of  cor- 
puscular degeneration."  ^ 

The  blood  of  burned  animals  contains  toxins  (Kijanitzenj, 
and  so  does  the  urine  (Reis).  It  seems  probable  that  the 
constitutional  symptoms  and  death,  if  it  occurs,  are  due 
partly  to  corpuscular  disorganization,  and  partly  to  the 
absorption  of  toxic  matter  from  the  seat  of  injury,  this  matter 
having  been  formed  by  the  action  of  heat  on  the  body-cells 
and  fluids.  Sepsis  is  not  infrequent.  The  symptomatic 
stages  are  often  designated  as  prostration,  reaction,  and  suppu- 
ratioji.  Death  may  be  directly  due  to  shock,  to  sepsis,  to 
exhaustion,  to  embolism  or  thrombosis,  to  congestion  of 
the  brain,  lungs,  or  kidneys,  or  to  Curling's  ulcer  of  the 
duodenum. 

Treatment. — The  local  treatment  of  slight  burns  (as  sun- 
burn) is  to  moisten  the  parts  frequently  with  a  saturated 
solution  of  bicarbonate  of  sodium,  a  solution  of  citrate  of 
lime,  or  a  1:8  solution  of  phenol  sodique.  In  burns  of 
moderate  degree  a  mixture  of  zinc  ointment  with  iodoform,, 
though  not  antiseptic,  is  a  comfortable  dressing. 

If  a  large  surface  is  burnt,  remove  the  clothing  with  great 
care,  and    before    applying    dressings,  give  a  hypodermatic 

'  Bardeen,  m  Johns  Hopkins  Hospital  Bulletin,  April,  1897. 


BC^J^.VS  A, YD    SCALDS.  913 

injection  of  morphin,  administer  stimulants,  and  if  the  patient 
has  a  chill  place  him  in  a  warm  bath.  If  we  desire  to 
dress  a  large  burn  aseptically,  anesthetize  the  patient,  spray 
the  burnt  area  with  peroxid  of  hydrogen,  irrigate  it  with 
a  solution  of  boric  acid,  dry  with  sterile  cotton,  dust  with 
iodoform  or  with  Senn's  powder  (three  parts  of  boric  acid 
and  one  part  of  salicylic  acid),  and  dress  with  salicjdated 
cotton.  Change  the  dressing  no  oftener  than  is  required, 
and  at  each  change  proceed  as  above  described,  although 
it  will  not  be  necessary  to  anesthetize.  The  custom  in 
the  Jefferson  Medical  College  Hospital  is  to  give  morphin 
and  stimulants,  to  cut  away  the  clothing,  to  wrap  the 
unburnt  parts  with  blankets,  and  place  about  them  cans 
or  bags  of  hot  water.  The  burnt  region  is  sprayed  with 
peroxid  of  hydrogen  contained  in  an  atomizer,  and  irrigated 
with  salt  solution.  Portions  of  epidermis  which  remain  are 
retained.  Any  blisters  are  opened  with  a  sterile  needle,  and 
the  part  is  dressed  with  several  layers  of  sterile  lint  or  tarla- 
tan soaked  in  normal  salt  solution,  and  the  dressing  is  kept 
moist. 

The  picric  acid  treatment,  first  suggested  by  Thiery,  has 
many  advocates.  It  should  be  used  early  only  in  limited 
burns  of  the  first  and  second  degrees,  but  it  can  be  used  in 
late  stages  of  deep  burns  to  stimulate  the  formation  of  epi- 
dermis. If  used  early  in  a  large  or  a  deep  burn,  it  may  poison 
the  patient  (may  produce  carboluria).  The  part  should  be  dis- 
infected, gauze  saturated  with  a  i  per  cent,  watery  solution  of 
picric  acid  should  be  laid  upon  the  burnt  area,  and  be  covered 
with  absorbent  cotton  and  a  bandage.  This  dressing  is  not 
changed  for  three  to  five  days,  and  the  next  dressing  can  be 
left  in  place  until  the  burn  is  healed.  D'Arcy  Power  has 
carefully  studied  the  real  status  of  picric  acid  as  a  remedy 
for  burns,  and  some  of  his  conclusions  have  been  set  forth 
above. 

Perier  dresses  a  burn  with  a  tarlatan  compress,  folded  six 
times  and  soaked  in  the  following  solution :  boric  acid, 
oijss;  antipyrin,  3jss;  sterile  water,  5viij.  The  following  oint- 
ment is  used  by  Reclus  :  iodoform,  gr.  xv;  antipyrin,  gr. 
Ixxv ;  boric  acid,  gr.  Ixxv ;  vaselin,  ijss. 

Carron  oil  consists  of  equal  parts  of  linseed  oil  and  lime- 
water.  It  allays  the  pain  of  a  burn,  but  it  is  a  filthy  prepa- 
ration, and  its  use  is  followed  by  much  pus-formation. 
Cosmolin  gives  comfort  as  a  dressing,  but  should  not  be 
used  on  the  face  lest  it  cause  pigmentation.  The  elder 
Gross  used  lead  paint.     A  solution  of  nitrate  of  potassium 

58 


914  BURNS  AND   SCALDS. 

allays  the  pain.  Where  extensive  destruction  of  tissue  has 
taken  place  use  splints  and  extension  to  limit  contractures, 
and  skin-graft  as  soon  as  possible.  If  granulation  is  slow, 
stimulate  with  copper-sulphate  or  mild  silver-nitrate  solu- 
tions. Exuberant  granulations  require  burning  down. 
Flabby  granulations  require  pressure.  If  healing  is  slow, 
or  if  the  burn  is  extensive,  skin-graft.  When  an  extremity 
has  been  carbonized  amputation  must  be  performed.  The 
constitutional  treatment  is  to  bring  about  reaction;  combat 
pain  with  opium  ;  and  keep  the  bowels  and  kidneys  active. 
If  suppuration  occurs,  give  tonics,  stimulants,  and  concen- 
trated foods.  Complications  are  treated  according  to  general 
rules. 

Scalds  of  the  glottis  are  due  to  the  inhalation  of  steam 
or  of  ignited  gas.  A  child  may  scald  the  glottis  by  trying 
to  drink  from  the  spout  of  a  kettle  (Moullin). 

The  symptoms  are  pain,  dysphagia,  and  dyspnea.  Edema 
of  the  glottis  comes  on  quickly. 

The  treatment  is  tracheotomy  or  intubation  of  the  larynx 
in  severe  cases;  in  mild  cases,  scarification  of  the  lai"ynx. 

Effects  of  Cold. — Local  Effects. — Cold  produces  numb- 
ness, pricking,  a  feeling  of  weight,  redness  of  the  surface 
followed  by  stiffness,  local  insensibility,  and  mottling  or 
pallor.  Sudden  intense  cold  causes  the  formation  of  blebs, 
the  coagulation  of  blood  in  the  superficial  veins,  and  vio- 
lent pain  in  the  limb.  Cold  locally  produces  frost-bite  (page 
162). 

The  constitutional  effects  of  cold  are  at  first  stimulating, 
then  depressing,  and  are  exhibited  by  uneasiness,  pain,  and 
an  intense  drowsiness  which,  if  yielded  to,  is  the  road  to 
death  by  way  of  internal  congestion.  Death  from  prolonged 
cold  resembles  in  appearance  death  from  apoplexy.  Death 
from  sudden  and  overwhelming  cold  is  caused  by  anemia 
of  the  brain  from  weak  circulation  and  capillary  embolism. 
To  bring  a  partly-frozen  person  into  a  warm  room  may  cause 
death  by  embolism. 

Treatment. — Frost-bite  is  treated  as  outlined  on  page  162. 
When  a  person  is  nearly  frozen  to  death  place  him  in  a  cool 
room,  but  under  no  circumstance  in  a  cold  bath,  make 
artificial  respiration,  rub  him  briskly  wdth  flannel  soaked  in 
alcohol  or  in  whiskey,  and  follow  this  by  rubbing  with  dry 
hands.  After  a  time  wrap  the  patient  in  warm  blankets  and 
give  an  enema  of  brandy.  Mustard  plasters  are  to  be  applied 
over  the  heart  and  spine.  As  soon  as  swallowing  is  possible 
brandy  is   administered  by  the   mouth.     As    the    condition 


DISEASES   OF   THE   SKIN  AND   NAILS.  91*5 

improves  gradually  raise  the  temperature  of  the  room  and 
give  liot  drinks. 

Chilblain,  or  pernio,  is  the  secondary  effect  of  cold.  It 
usually  appears  as  a  local  congestion  upon  the  toes,  the  ears, 
the  fingers,  or  the  nose,  and  it  is  apt  now  and  then  to  inflame 
and  ulcerate.  A  chilblain  is  apt  to  become  congested  by 
approaching  a  fire  or  by  taking  exercise,  and  when  con- 
gested it  itches,  tingles,  and  stings.  Frequent  attacks  of 
congestion  produce  crops  of  vesicles ;  these  vesicles  rupture 
and  expose  an  ulcer,  which  in  rare  instances  sloughs. 

Treatment. — If  chilblain  affects  the  toes,  prevent  con- 
gestion of  the  legs  and  feet.  Order  large  shoes  and  woollen 
stockings,  and  forbid  tight  garters.  The  patient  with  pernio 
must  take  regular  outdoor  exercise  and  must  not  loiter  around 
a  hot  fire!  Every  morning  and  evening  he  should  take  a 
general  cold  sponge-bath,  following  by  rubbing  with  alcohol 
and  frictions  with  a  coarse  towel,  and  in  winter  he  should 
sleep  with  warm  stockings  on  or  with  his  feet  upon  a  hot- 
water  bag.  When  a  chilblain  is  only  a  congested  spot  it 
should  be  washed  twice  a  day  in  cold  salt  water,  rubbed  dry 
with  flannel,  and  subjected  to  applications  of  tincture  of 
iodin  and  soap  liniment  (i  :  2),  tincture  of  cantharides  and 
soap  liniment  (i  :  6),  or  equal  parts  of  turpentine  and  olive 
oil  (W.  H.  A.  Jacobson).  Jacobson  says  itching  is  relieved 
by  painting  belladonna  liniment  upon  the  part  and  allowing 
it  to  dry.  If  vesicles  form,  paint  with  contractile  collodion ; 
if  ulcers  form,  dress  antiseptically.  If  ulcers  are  sluggish, 
use  equal  parts  of  resin  cerate  and  spirits  of  turpentine.  A 
good  antiseptic  and  protective  is  the  following:  oxid  of 
zinc,  gr.  vj ;  chlorid  of  zinc,  gr.  xx ;  gelatin,  sij ;  distilled 
water,  3j. 

XXXI.    DISEASES  OF  THE  SKIN  AND  NAILS. 

Dermatitis  venenata  results  from  irritants  and  from 
garments  containing  arsenic,  but  is  generally  due  to  rhus- 
poisoning.  Rhus-poisoning  arises  from  the  poison-oak,  the 
poison-ash,  the  poison-ivy,  and  other  species  of  sumach. 
Actual  touching  of  the  plants  is  not  always  necessary. 

The  symptoms  are  burning  and  itching,  redness  and 
edema  of  the  face  and  hands.  A  vesicular  eruption  begins 
between  the  fingers,  and  the  eruption  and  the  inflammation 
spread  widely  over  the  body.     There  may  be  slight  fever. 

The  treatment,  when  a  moderate  area  is  involved,  com- 
prises the  application  of  cloths  wet  with  black  wash  or  lead- 


gi6  DISEASES   OF   THE   SKIN  AND   NAILS. 

water  and  laudanum.  If  an  extensive  area  is  involved, 
apply  grindelia  robusta  (oiv  to  Oj  of  water)  or  moisten  the 
surface  frequently  with  sweet  spirits  of  niter.  Oxid-of-zinc 
ointment  containing  lo  gr.  of  carbolic  acid  to  5J  gives  great 
relief  A  I  :  8  solution  of  phenol  sodique  allays  pain  and 
itching. 

Furuncle,  or  boil,  is  an  acute  and  circumscribed  inflam- 
mation of  the  deep  layer  of  the  true  skin  and  the  subcuta- 
neous cellular  tissue  following  on  bacterial  infection  of  a 
hair-follicle  or  a  sebaceous  gland.  A  boil  is  caused  by  infec- 
tion of  a  hair-follicle,  through  a  slight  wound  (by  scratching, 
shaving,  etc.),  with  the  staphylococcus  pyogenes  aureus. 
Boils  are  very  common  in  individuals  with  Bright's  disease, 
diabetes,  gout,  tuberculosis,  and  disorders  of  menstruation 
and  digestion ;  and  crops  of  boils  are  apt  to  appear  during 
convalescence  from  typhoid  fever.  Boils  are  commonest  in 
the  spring,  and  sometimes  an  epidemic  of  furunculosis 
appears  in  a  hospital,  a  jail,  or  an  asylum. 

The  symptoms  of  a  boil  are  as  follows  :  a  red  elevation 
appears,  which  stings  and  itches ;  this  elevation  enlarges  and 
becomes  dusky  in  color;  a  pustule  forms,  that  ruptures  and 
gives  exit  to  a  very  little  discharge  which  forms  a  crust.  In- 
flammatory infiltration  of  adjacent  connective  tissue  advances 
rapidly,  and  the  boil  in  about  three  days  consists  of  a  large, 
red,  tender,  and  painful  base  capped  by  a  pustule  and  a  little 
crusted  discharge.  In  rare  instances,  at  this  stage,  absorp- 
tion occurs,  but  in  most  cases  the  swelling  increases,  the  dis- 
coloration becomes  darker,  the  skin  becomes  edematous,  the 
pain  becomes  fierce  and  pulsatile,  and  the  center  of  the  boil 
becomes  raised.  About  the  seventh  day  rupture  occurs, 
pus  flows  out,  and  a  "core"  of  necrosed  tissue  is  found  in 
the  center  of  a  ragged  opening.  This  core  consists  of  the 
sebaceous  gland  and  hair-follicle,  which  have  undergone 
coagulation-necrosis  (Warren).  In  a  day  or  two  more  the 
core  will  be  discharged,  and  healing  by  granulation  will 
occur.  A  blind  boil  lasts  only  three  or  four  days  and  has 
no  core.  The  constitution  often  shows  reaction  during  the 
progress  of  a  boil.  Boils  may  be  either  single  or  multiple. 
The  development  of  one  boil  after  another,  or  the  formation 
of  several  boils  at  once,  is  known  as  "furunculosis."  Boils 
arc  commonest  upon  the  neck  and  the  back. 

The  treatment  consists  of  crucial  incision,  removal  of 
necrotic  tissue,  irrigation  with  peroxid  of  hydrogen  and  cor- 
rosive sublimate,  and  the  application  of  hot  antiseptic  fomen- 
tations. 


CARBUNCLE.  917 

Aleppo  boils  (endemic  boils  of  the  tropics)  are  papules 
appearing  upon  the  exposed  parts  of  the  body.  These 
papules,  which  ulcerate  and  do  not  cicatrize  for  at  least  a 
year,  are  due  to  a  pathogenic  bacterium  and  leave  ineradi- 
cable scars. 

Carbuncle  (benign  anthrax)  is  a  circumscribed  infectious 
inflammation  of  the  deeper  layer  of  the  true  skin  and  of 
the  subcutaneous  tissue,  with  fibrinous  exudation,  multiple 
foci  of  necrosis  arising,  and  the  tissue  adjacent  to  each 
necrotic  plug  becoming  gangrenous.  The  infection  takes 
place  through  a  hair-follicle.  It  is  really  a  boil  with  exten- 
sive infiltration  of  adjacent  tissues.  A  boil  may  become  a 
carbuncle,  and  pus  from  a  carbuncle  inoculated  into  a  healthy 
person  may  cause  either  a  boil  or  a  carbuncle.  The  causa- 
tive organism  seems  to  be  the  staphylococcus  pyogenes 
aureus.  Carbuncles  are  most  common  in  the  spring  of  the 
year.  In  persons  with  diabetes  and  Bright's  disease  carbun- 
cles not  unusually  occur. 

The  local  symptoms  in  the  beginning  resemble  those  of  a 
boil,  but  the  constitution  sympathizes  from  the  very  start  (a 
chill  and  a  septic  fever)  and  the  pain  is  usually  severe.  The 
inflammatory  area  begins  as  a  papule  with  an  indurated  base, 
it  enlarges  enormously,  is  boggy  to  the  touch,  is  dusky  in 
color,  is  edematous,  and  the  skin  is  not  freely  movable  over 
the  deeper  parts.  In  a  few  days  many  pustules  appear, 
each  pustule  marking  the  site  of  a  focus  of  necrosis.  Large 
vesicles  filled  with  bloody  serum  very  frequently  form.  In 
some  cases,  about  the  tenth  day,  the  pustules  rupture,  the 
necrotic  plugs  are  discharged,  and  the  case  slowly  progresses 
toward  cure;  but  in  many  cases  the  carbuncle  spreads  at 
the  periphery  while  pustules  are  rupturing  near  the  center 
of  inflammation,  and  pus  forms  in  the  deeper  tissues,  reach- 
ing the  surface  through  many  small  openings,  each  of  which 
is  partly  blocked  by  a  plug  of  dead  tissue.  A  carbuncle  in 
this  stage  resembles  a  honeycomb,  discharges  bloody  pus, 
and  large  masses  of  skin  and  subcutaneous  tissue  are 
destroyed.  The  entire  carbuncular  mass  may  become  gan- 
grenous, and  a  sudden  and  almost  complete  cessation  of 
pain  points  to  this  complication.  An  ordinary  carbuncle 
remains  acute  for  about  three  weeks,  but  healing  requires  a 
month  more.  The  most  dangerous  situations  in  which  to 
have  a  carbuncle  are  the  face  and  neck  (tends  to  produce 
septic  phlebitis,  septic  clots  in  the  cerebral  sinuses,  or  infec- 
tive emboli).  The  most  usual  positions  for  carbuncle  are 
the  neck,  the  back,  and  the  buttocks.     The  diagnosis  of  car- 


91 8       DISEASES   OF   THE   SKIN  AND   NAILS. 

buncle  is  made  by  noting  the  multiple  foci  of  necrosis  and 
the  profound  constitutional  involvement.  A  carbuncle  may 
produce  death  by  causing  septicemia,  pyemia,  or  profuse 
hemorrhage. 

Treatment. — Some  have  suggested  the  treatment  of  a 
carbuncle  in  an  early  stage  by  injecting  from  five  to  thirty 
drops  of  carbolic  acid  (80  per  cent.)  into  and  around  the 
inflammatory  mass.  The  best  treatment  is  thorough  extir- 
pation while  the  patient  is  anesthetized.  The  entire  area  of 
the  infection  is  thus  removed,  and  the  large  wound  heals  by 
granulation  and  is  subsequently  skin-grafted.  A  useful 
plan,  frequently  employed,  is  as  follows  : 

Give  ether,  make  free  crucial  incisions,  remove  dead  and 
necrosing  tissue  with  the  scissors  and  forceps,  curet  pockets, 
arrest  hemorrhage  by  pressure  and  hot  water,  cauterize  with 
piive  carbolic  acid,  dust  with  iodoform,  pack  with  iodoform 
gauze,  and  dress  with  hot  antiseptic  fomentations.  Cover 
the  gauze  with  a  piece  of  some  impermeable  material  and 
lay  a  hot-water  bag  upon  the  dressing.  Eveiy  day,  or  sev- 
eral times  a  day,  remove  the  dressings,  wash  Avith  peroxid 
of  hydrogen,  irrigate  with  corrosive-sublimate  solution,  dust 
with  iodoform,  and  reapply  the  iodoform  gauze  and  anti- 
septic fomentation.  Keep  up  this  treatment  until  sloughs 
are  separated,  and  then  dress  with  dry  antiseptic  gauze. 
Secure  sleep  by  morphin,  give  quinin,  milk-punch,  and  nour- 
ishing diet,  and  attend  to  the  bowels  and  kidneys. 

Clavus,  or  Corn. — A  corn  is  a  tender,  painful,  and  cir- 
cumscribed thickening  of  the  epidermis,  and  is  commonest 
over  one  of  the  joints  of  the  toes.  Hard  corns  are  situated 
on  exposed  parts  of  the  digits ;  soft  corns  appear  between 
the  digits,  where  the  parts  are  kept  constantly  moist.  Corns 
are  caused  by  pressure. 

Treatment. — By  wearing  well-fitting  boots  corns  upon 
the  toes  will  usually  disappear.  Soak  the  feet  often  in  water 
containing  bicarbonate  of  sodium,  dry  them,  and  apph'  a 
circular  corn-plaster  to  the  corn  to  take  off  the  pressure  of 
the  boot.  Another  method  is  to  touch  the  corn  with  iodin 
every  night  and  pare  away  the  hard  tissue  every  morning. 
An  old  and  valuable  plan  is  to  paint  the  corn  every  night 
with  a  mixture  composed  of  salicylic  acid,  .5iss  ;  extract  of 
cannabis  indica,  gr.  x;  and  collodion,  sj,  and  to  scrape  this 
mixture  away  every  morning.  Soft  corns  are  treated  by 
washing  the  feet  often  with  ethereal  soap,  drying,  gently 
removing  the  sodden  epithelium,  dusting  the  toes  with 
borated    talc,    and    placing    absorbent    cotton    between    the 


ivoi'XDS.  9^9 

dicrits  Incurable  soft  corns  require  the  removal  of  the  skin 
from  the  adjacent  sides  of  the  two  toes  and  sutunng  them 
tocrether  (thus  converting  two  toes  into  one).  In  inflamed 
corns  employ  rest  and  lead-water  and  laudanum,  and  let  out 
pus  when  it  forms.  Remember  that  in  old  persons  the  cut- 
tincT  of  a  corn  may  cause  senile  gangrene.  In  the  mflamed 
and  painful  feet  of  a  person  who  has  corns  nothmg  gives  so 
much  relief  as  washing  the  feet  with  ethereal  soap,  soaking 
in  hot  water,  and  wrapping  the  feet  for  half  an  hour  m  cloths 
wet  with  a  mixture  composed  of  linseed  oil  and  lime-water, 
each,  sij,  and  spirits  of  camphor,  oj- 

Warts.— (See  page  291.)  ■       r  ,1  -i       a 

Onychia  is  inflammation  of  the  matrix  ot  the  naii.  .-\ 
"run-around"  is  suppuration  of  the  matrix  and  the  root  of 
the  nail  of  traumatic  origin.  It  requires  incision,  trimming 
awa>-  of  the  buried  edge  of  the  nail,  and  packing  with  iodo- 
form gauze. 

Malignant  ouyclda,  which  is  inflammation  and  ulceration 
of  the  entire  matrix,  occurs  only  in  a  person  of  dilapidated 
constitution.  This  condition  requires  removal  of  the  entire 
nail  cauterization  of  the  matrix,  dressing  with  lodoiorm 
gauze,  and  the  internal  use  of  stimulants,  tonics,  and  nour- 
ishing diet.  .  1  r 
Ingrozun  toe-nail  is  due  either  to  lateral  hypertrophy  ol 
the  ellcre  of  the  nail  or  to  the  forcing  of  the  soft  tissues  over 
the  mal-gin  of  the  nail.  The  condition  is  treated  by  splitting 
the  nail,  removing  the  piece  of  nail,  the  soft  tissue,  and  the 
adjacent  matrix,  and  dressing  antisepticall}-. 

XXXII.  DISEASES   AND    INJURIES  OF  THE    THYROID 

GLAND. 

Wounds  cause  violent  hemorrhage  which  is  difficult  to 
arrest  Ligatures  may  cut  out  and  forceps  will  not  hold.  The 
hemorrhage  is  arrested  bv  suture-ligatures,  purse-stnng  su- 
tures the  actual  cautery,  or  removal  of  the  bulk  of  the  gland. 

The  th^-roid  gland  ma^'  be  absent  at  birth.  Congenital 
atrophy' or  congenital  hypertrophy  may  exist. 

Acquired  atrophy  leads  to  myxedema,  a  condition  char- 
acterized by  the  presence  of  a  firm  subcutaneous  swelling  in 
the  face.  neck,  and  limbs  ;  slow  speech ;  mental  dulness  ;  and 
subnormal  temperature.  The  condition  is  identical  with  that 
produced  by  removal  of  the  entire  gland  (cachexia  struma- 

priva).  ,        r     1       1 

Cretinism  is  a  form  of  idioc)-  due  to  atrophy  oi  glanau- 


920  DISEASES  AND   INJURIES   OF  THE    THYROID  GLAND. 

lar  elements  in  the  thyroid,  although  the  size  of  the  gland  is 
often  increased.  The  body  is  dwarfed ;  the  face,  neck,  and 
extremities  resemble  those  parts  in  myxedema,  and  a  low 
grade  of  idiocy  exists.  Myxedema  and  cretinism  are  treated 
by  the  internal  administration  of  thyroid  extract. 

Congestion  of  the  thyroid  may  be  caused  by  violent 
exertion,  prolonged  effort,  febrile  maladies,  and  venous  ob- 
struction. It  is  treated  by  removing  the  cause  and  applying 
heat  locally.     Tracheotomy  may  be  required. 

Inflammation  of  the  thyroid  (acute  or  inflammatory 
goiter)  may  be  caused  by  a  septic  or  febrile  malady,  rheu- 
matism, muscular  strain  causing  vascular  rupture,  a  wound 
or  contusion  of  the  thyroid.  But  one  lobe  is  affected.  The 
ordinary  symptoms  of  inflammation  are  present.  In  addition 
there  are  dysphagia,  dyspnea,  venous  congestion  of  the  face, 
epistaxis,  nausea  and  vomiting,  and  possibly  delirium.  It 
may  terminate  in  resolution,  suppuration,  or  fibrous  indura- 
tion. 

Goiter. — A  goiter  is  an  enlargement  of  the  thyroid  gland 
not  due  to  malignant  tumor  or  to  inflammation.  Goiter  may 
affect  a  portion  of  one  lobe,  both  lobes,  or  both  lobes  and  the 
isthmus,  and  it  may  occur  sporadically  or  endemically.  In 
Switzerland  it  is  very  common.  Among  the  alleged  causes  are 
the  playing  of  wind-instruments,  the  drinking  of  snow-water, 
and  the  use  of  water  impregnated  with  the  salts  of  lime.  He- 
reditary influence  is  frequently  noted.  The  forms  of  goiter 
are  as  follows :  simple  liypertropliy,  a  hypertrophy  of  the 
gland-tissue,  usually  symmetrical,  in  reality  an  adenoma ; 
cystic  goiter  or  bronchocele ,  in  which  cysts  form  in  hypertro- 
phied  glands,  or  rarely  in  non-hypertrophied  thyroids,  the 
cysts  being  either  single  or  multiple,  being  due  to  mucoid  or 
colloid  degeneration,  and  containing  a  fluid  sometimes  clear 
and  thin,  sometimes  viscid,  and  often  coffee-ground  in  char- 
acter; ^XiA  fibrous  goiter,  a  fibrous  induration  which  is  apt  to 
arise  in  old  bronchoceles,  and  which  may  pass  into  a  calca- 
reous condition.  Parenchymatous  goiter  is  enlargement  of 
the  whole  gland.  By  the  term  malignant  goiter  we  mean 
malignant  disease  of  the  thyroid  gland,  either  sarcoma  or 
carcinoma. 

The  symptoms  are — congestion  of  the  head  and  neck  from 
enlargement  of  veins  ;  occasionally  cerebral  symptoms  (ane- 
mia, -sj^ncope,  even  convulsions)  from  pressure  on  carotids ; 
irritation  of  recurrent  laryngeal  nerve  (causing  spasm  of  the 
glottis  or  laryngeal  paralysis) ;  compression  of  the  trachea 
(causing  dyspnea).     Rapidly-growing  goiters  are  often  fatal; 


EXOPHTHALMIC   GOITER.  92  I 

slow-growing  goiters  are  rarely  fatal.  A  goiter  moves  up 
and  down  as  the  patient  swallows.  A  malignant^ goiter  grows 
rapidly,  becomes  adherent,  infiltrates,  and  quickTy"produces 
metastasis.  Both  sarcoma  and  carcinoma  produce  metasfasis 
b)-  way  of  the  venous  system. 

Treatment. — lodid  of  potassium  and  arsenic  internally 
have  been  advised  ;  ointment  of  red  oxid  oi  mercury  locally 
is  advocated  by  some  writers.  The  local  use  of  iodin  benefits 
many  cases.  The  administration  of  thyroid  extract  may  do 
much  good.  Cystic  goiters  ma}-  be  aspirated  and  injected 
with  a  solution  of  iodin.  Electrolysis  may  benefit  a  soft 
goiter,  the  negative  pole  being  pushed  into  the  growth,  the 
positive  pole  being  applied  to  its  surface.  In^jconsklering 
the  propriety  of  operation  remember  that  a  goiteti-whieh 
begins  at  puberty  may  pass  away.  We  should  operate  on 
every  non-malignant  goiter  which  is  increasing  rapidly  in  size, 
and  on  evej_y  goiter  which  causes  much  respiratoiy  trouble, 
but  should  not  operate  simply  for  deformity  (Bergeat).  If 
enucleation  or  extjrpation  is  performed,  do  not  give  ether  or 
chloroform.  These  agents  greatly  increase  bleeding,  and  are 
dangerous.  Do  the  operation  with  the  aid  of  local  anesthesia 
(cocain.  eucain,  or  Schleich's  fluid).  It  is  a  great  advantage 
to  have  the  patient  conscious,  because  by  asking  him  to 
speak  during  the  operation  the  surgeon  can  tell  if  the  re- 
current laryngeal  nerve  is  being  touched.  In  most  cases 
intraglandular  enucleation  is  performed,  in  some  cases  extra- 
glahdirlar  enucleation,  in  other  cases  these  two  methods  are 
combined  (Bergeat).  Ligation  of  the  thyroid  arteries  has 
been  recommended.  Enucleation,  if  possible,  is  the  desirable 
operation.  It  ma}-  easil}-  be  employed  for  the  removal  of  a 
single  colloidal  or  cystic  area  (Socin).  Thyroidectorn}'  or 
extirpation  is  employed  when  enucleation  is  impossible. 
The  entire  thyroid  is- not  removed  for  an  innocent  growth  ;  a 
portion  of  the  gland  is  left  behind,  otherwise  myxedema  will 
arise  (Kocher).  Unilateral  extirpation  is  the  usual  method. 
In  sarcoma  or  cancer  of^  the  thyroid  complete  extirpation 
may  be  attempted.  The  operation  will  occasional!}-  prolong 
life,  but  it  will  rare!}*  effect  a  cure. 

Bxophth.almic  Goiter  fGraves's  Disease ;  Basedow's 
Disease  ;  Pulsating  Goiter). — In  a  t}-pical  case  there  are  rapid 
pulse,  protrusion  of  the  eyeballs,  and  enlargement  of  the  thy- 
roid gland  :  but  an}-  one  of  these  conditions  ma}-  be  absent. 
The  enlargement  ma}*  be  unilateral,  but  is  usually  bilateral. 
A  systolic  bruit  is  usualh-  audible  over  the  thyroid  region. 
Von  Graefe's  sign  may  be  present ;  this  consists  of  retraction 


922   DISEASES  AND   INJURIES  OF   THE    THYROID   GLAND. 

of  the  eyelids,  and  inability  of  the  lids  to  follow  the  eyes  in 
looking  down.  The  lids  in  some  cases  cannot  be  completely 
closed,  and  when  the  eyeball  is  suddenly  turned  up  the  lid 
and  brow  may  fail  to  act  together.  In  some  cases  the  lids 
pulsate,  in  some  ocular  palsies  exist,  in  others  photophobia  or 
nystagmus.  Patients  may  suffer  from  neuralgia,  colic,  choreic 
movements,  tremor,  flushes  of  heat,  and  gastric  crises.  Dysp- 
nea often  exists,  and  albuminuria  and  polyuria  are  not  un- 
common. Hemoptysis,  hematemesis^  or  mental  disturbance 
is  sometimes  noted. 

Exophthalmic  goiter  may  arise  after  emotional  excitement 
or  depression,  during  pregnancy,  or  during  the  existence  of 
locomotor  ataxia,  paresis,  epilepsy,  neurasthenia,  hysteria, 
and  other  nervous  troubles.  The  condition  is  a  vasomotoF 
ataxia  (Cohen).  Its  real  cause  is  uncertain ;  but  is  probably 
the  action  upon  the  sympathetic  system  of  some  poisonous 
product  of  thyroid  action. 

Treatment. — Thyroid  extract  more  often  does  harm  than 
good.  Electricity  Ts^  said  to  be  of  benefit.  Most  cases  are 
treated  by  improving  the  general  health  and  employing  digi- 
talis. Thymus  extract  and  suprarenal  extract  have  been  used 
by^some.  Extirpation  of  thV  cervical  ganglion  of  the  sym- 
pathetic, and  division  of  the  nerve  below  the  ganglion,  have 
been  employed,  and  it  is  alleged  with  benefit  (Jaboulay).  Liga- 
tion of  the  thyroid  arteries  may  do  good.  Incomplete  removal 
is  the  operation  commonly  employed  in  severe  cases  ;  it  has 
cured  8o_perj:ent.  of  the  cases  operated  upon.  In  some  cases 
thyroid  intoxication  follows  operation.  In  other  cases  very 
rapid  growth  follows  incomplete  removal,  and  the  operation 
seems  actually  to  have  done  harm.  Sudden  death  occasion- 
ally follows  the  operation  of  thyroidectomy.  The  removal 
of  an  exophthalmic  goiter  is  difficult ;  the  capsule  and  blood- 
vessels rupture  from  slight  force,  and  the  use  of  ether  and 
chloroform  is  very  dangerous.  All  cases  should  not  be 
operated  upon ;  in  fact,  only  those  cases  should  be  operated 
upon  in  which  medical  treatment  has  proved  futile,  or  in  which 
there  is  profound  toxemia  or  excessive  dyspnea.  If  the 
operation  is  performed,  neither  ether  nor  chloroform  should 
be  given,  as  either  of  these  agents  will  greatly  increase  bleed- 
ing and  prove  dangerous.  Operation  is  to  be  done  under 
local  anesthesia  (eucain,  cocain,  or  Schleich's  fluid). 


INFECTIVE   L  YMPIIADENITIS.  923 


XXXm.     D15EA5ES  AND  INJURIES  OF  THE 
LYMPHATICS. 

I/ytnphang"itis  is  inflammation  of  lymphatic  vessels.  Re- 
ticular lymphangitis,  which  is  inflammation  of  lymphatic 
radicals,  is  seen  in  some  circumscribed  inflammations  of  the 
skin.  It  is  apt  to  attack  the  hands,  causing  redness  and 
swelling,  fading  at  the  point  of  initial  trouble  while  it  spreads 
at  the  periphery ;  it  is  caused  by  micro-organisms  derived 
from  decomposing  animal  matter  (Rosenbach).  Erysipelas 
also  causes  it  (see  Erysipelas).  Tubular  lymphangitis,  which 
is  due  to  the  entry  into  the  lymphatic  ducts  of  virulent  micro- 
organisms or  toxic  materials,  is  seen  after  dissecting-wounds, 
septic  wounds,  snake-bites,  etc.  It  is  announced  by  edema 
and  by  minute,  hard  red  streaks  running  from  the  wound  up 
the  extremity.     Suppuration  may  occur. 

Infective  lymphadenitis,  or  inflammation  of  the  glands, 
may  follow  lymphangitis  or  may  be  due  to  the  deposition  of 
infective  material,  the  lymph-vessels  not  being  inflamed.  In 
septic  lymphadenitis  there  are  pain,  tenderness,  and  swelling ; 
in  severe  cases  there  is  a  chill  and  a  septic  fever.  Suppura- 
tion may  arise.  The  trcat7nent  is  to  drain  and  asepticize  the 
wound,  to  apply  iodin,  blue  ointment,  or  ichthyol  over  the 
glands  and  vessels,  and  to  employ  rest  and  compression. 
Internally,  milk  punch,  quinin,  and  nourishing  diet  are  re- 
quired. If  the  glands  do  not  rapidly  diminish  in  size  after 
disinfection  of  a  wound,  and  if  they  are  in  an  accessible 
region,  extirpate  them.  If  suppuration  of  the  glands  occurs, 
incise  and  drain. 

Acute  lymphadenitis,  or  acute  inflammation  of  the  lym- 
phatic glands,  maybe  due  to  tubercle,  syphilis,  glanders,  cold, 
or  traumatism.  Suppuration  may  or  may  not  occur.  In  in- 
flammatory lymphadenitis  there  are  pain,  heat,  and  nodular 
swelling.     In  severe  cases  there  is  fever. 

The  treatment  is  to  asepticize  any  area  of  infection,  place 
the  glands  at  rest,  apply  cold  and  ichthyol  ointment,  or 
inject  into  the  gland  every  day  5  minims  of  a  3  per  cent, 
solution  of  carbolic  acid  to  prevent  suppuration.  If  the 
glands  do  not  rapidly  shrink,  extirpate  them.  If  pus  forms, 
evacuate,  drain,  and  asepticize. 

Chronic  lymphadenitis  is  almost  invariably  syphilitic  or 
tubercular.  It  requires  constitutional  treatment  and  the 
local  use  of  ichthyol,  iodin,  or  blue  ointment.  If  these  rem- 
edies are  not  rapidly  successful,  tubercular  glands  should  be 


924      DISEASES  AND   IXJURIES   OF   THE   LYMPHATICS. 

removed,  but  syphilitic  glands  will  rarely  require  such  radi- 
cal treatment. 

I/ytnphangiectasis  (varicose  lymphatics),  or  dilatation 
of  the  lymphatic  vessels,  is  due  to  obstruction.  It  results, 
as  a  rule,  from  chronic  lymphangitis  or  the  pressure  of  a 
tumor,  and  is  most  usually  situated  in  the  pubic,  the  ingui- 
nal, or  the  scrotal  region,  or  on  the  inner  side  of  the  thigh. 
There  are  two  forms  :  the  varicose,  in  which  the  vessels  have 
a  tortuous  outline,  like  varicose  veins,  but  are  covered  only 
with  surface-epithelium  ;  and  lymphatic  xvarts  (lymphangioma 
circumscriptum),  in  which  wart-like  masses  spring  up,  these 
masses  being  covered  with  epithelium  and  filled  with  lymph. 
In  most  cases  of  lymphangiectasis  there  is  considerable 
hard  edema.  Rupture  of  the  dilated  vessel  causes  a  flow 
of  lymph  ilyviplwrrheci). 

I/ymphangioma  is  an  advanced  stage  of  lymphangiec- 
tasis (p.  284). 

The  treatment  in  mild  cases  is  to  pierce  each  vesicle  with 
the  negative  pole  of  a  galvanic  battery  and  pass  a  current. 
In  severe  cases  destroy  the  mass  with  the  Paquelin  cautery 
or  excise  it  with  a  knife  or  with  scissors. 

Hlephantiasis. —  True  elephantiasis  (elephantiasis  Ara- 
bum)  is  chronic  hypertrophy  of  the  skin  and  subcutaneous 
tissues  following  upon  a  lymphangiectasis  produced  by  a 
nematode  worm  (the  filaria  sanguinis  hominis). 

Spurious  elephantiasis  is  hypertrophy  of  the  skin  and  sub- 
cutaneous tissue  due  to  chronic  inflammation  (in  a  leg  which 
possesses  an  ancient  ulcer,  or  in  the  scrotum  of  a  man  with 
urinary  fistula). 

The  treatment  is  massage  and  bandaging,  sometimes 
ligation  of  the  artery  of  supply,  extirpation,  or  amputation. 

Tubercular  Glands  (p.  196). 

I/ymphadenoma  {^Malignant  Lymphoma;  Hodgkin's 
Disease;  Pseudoleukemia). — The  term  lymphoma  is  used  to 
loosely  designate  any  persistent  swelling  of  a  lymphatic 
gland  or  glands.  Lymphadenoma  means  a  swelling  of 
lymph-glands  or  lymphadenoid  tissue,  which  swelling  is  pro- 
gressive in  character,  involves  group  after  group  of  glands, 
is  associated  with  anemia,  and  often  accompanied  by  sec- 
ondary growths  in  the  abdominal  viscera.  Fig.  344  exhibits 
a  case  of  Hodgkin's  disease. 

This  disease  is  most  common  in  those  under  forty,  and 
affects  males  far  more  frequently  than  females.  In  many 
cases  the  disease  arises  slowly  in  apparently  healthy  glands 
and  exists  for  some  time  before  it  takes  on  signs  of  malig- 


L  YMPIIADENOMA. 


925 


nancy  and  invades  distant  glands.  A  gland  enlarged  from 
irritation  or  from  tubercular  disease  may  become  lymphade- 
nomatous,  and  tubercle  bacilli  can  sometimes  be  found  in 
lymphadenomatous  glands.  In  some  cases  the  disease  has 
a  tendency  to  generalization  from  the  start ;  in  others  it 
appears  to  remain  localized  for  many  months  It  has  been 
thought  by  some  that  there  is  an  infective  element  which  is 


Fig.  344. — Hodgkin's  disease. 


responsible  for  the  disease,  but  causative  organisms  have  not 
been  found. 

Symptoms. — The  glands  in  the  neck  are  usually  involved 
first,  but  the  disease  may  begin  in  the  axillary  glands,  the 
thoracic  glands,  or  the  intra-abdominal  glands. 

Two  or  more  regions  are  sometimes  involved  simulta- 
neously or  almost  simultaneously. 

When  the  disease  begins  in  the  neck,  it  affects  at  first  one 
side,  and  after  many  weeks  or  months  the  other  side  becomes 
involved.     The  glands  are  at  first  hard,  separated  from  each 


926    DISEASES  AND    IXJURIES    OF   THE    L  YMPHA  TICS. 

other,  movable,  and  the  skin  moves  freely  over  them.  Later 
the  large  glands  weld  together  and  form  great  masses  upon 
both  sides  of  the  neck  and  in  the  axillae  which  may  obstruct 
respiration. 

After  a  time  a  very  large  mass  may  soften,  and  in  very 
rare  cases  the  skin  becomes  adherent  and  finally  breaks. 
Intrathoracic  symptoms  point  to  involvement  of  the  thoracic 
glands.     It  may  be  possible  to  palpate  abdominal  glands. 

The  spleen  is  enlarged ;  the  thyroid  may  be  enlarged ; 
anemia  is  usually  but  not  invariably  present,  and  if  it  exists, 
there  are  the  ordinary  symptoms  which  go  with  it,  viz.,  pal- 
pation, breathlessness,  indigestion,  vertigo,  headache,  pallor, 
and  sometimes  epistaxis.  Occasionally,  without  obvious 
reason,  the  glands  suddenly  increase  in  size,  or  rapidly 
undergo  a  notable  but  temporary  diminution. 

Osier  says  slight  fever  exists  in  almost  all  cases,  and  some- 
times there  are  paroxysms  like  ague.^ 

Diag-nosis. — In  a  widespread  case  the  diagnosis  is  easy ; 
in  a  localized  case  it  is  difficult.  Tubercular  glands  are  most 
apt  to  first  appear  in  the  submaxillary  triangle;  lymphadeno- 
matous  glands,  in  the  root  of  the  neck  or  in  the  occipital  tri- 
angle. Tubercular  adenitis  is  most  common  in  children.  As 
a  rule,  tubercular  glands  caseate,  but  they  may  remain  localized 
for  years  if  caseation  does  not  occur.  The  tubercular  glands 
usually  soon  become  adherent  and  immovable.  Lymphade- 
noma  is  most  common  after  twenty,  rarely  remains  localized 
for  more  than  a  few  months,  rarely  softens  unless  very  large, 
and  the  glands  are  separated  and  movable  until  a  huge  mass 
forms.  Early  softening,  prolonged  limitation  to  one  region, 
and  absence  of  pronounced  anemia  in  a  person  under  twenty 
point  to  tubercle.  In  doubtful  cases  a  gland  should  be 
removed  for  microscopical  and  bacteriological  study. 

Prognosis. — The  disease  is  almost  alw^ays,  if  not  invariably, 
fatal.  Most  cases  die  within  three  years,  some  die  wathin 
six  months,  some  few  live  four  or  five  years  or  more. 

Treatment. — If  the  glands  are  localized  to  one  side  of 
the  neck,  or  even  to  both  sides  of  the  neck,  remove  them. 
Early  removal  before  dissemination  has  occurred  may  pos- 
sibly save  the  patient.  If  early  or  radical  removal  is  not 
possible,  do  not  operate,  but  treat  the  patient  with  nutritious 
food,  tonics,  and  courses  of  arsenic. 

^  Osier's  Practice  of  Medicine. 


SPIRAL  REVERSED  BANDAGE  OF  UPPER  EXTREMITY.  927 

XXXIV.  BANDAQE5. 

A  bandage  is  a  fibrous  material  which  is  rolled  up  and  is 
then  employed  to  retain  dressings,  applications,  or  appliances 
to  a  part,  to  make  pressure,  or  to  correct  deformity.  It  may 
be  composed  of  plain  gauze,  of  gauze  infiltrated  with  plaster- 
of-Paris  or  soaked  in  silicate  of  sodium,  of  gauze  wet  with 
corrosive-sublimate  solution,  of  flannel,  of  calico,  or  of  un- 
bleached muslin.  Unbleached  muslin,  which  is  the  best 
material  for  general  use,  is  washed  to  remove  the  sizing, 
is  torn  into  strips,  and  the  edges  are  stripped  of  selvage. 
One  end  is  folded  to  the  extent  of  six  inches,  this  is  folded 
upon  itself  again  and  again  until  a  firm  center  is  formed, 
and  over  this  center  the  bandage  is  rolled.  In  a  well-rolled 
bandage  the  center  cannot  be  pushed  out  of  the  roll.  A 
roller  bandage  is  divided  into  the  initial  end,  which  is  within 
the  roll,  the  body  or  rolled  part,  and  the  terminal  end,  which 
is  free.  In  applying  a  bandage  the  outer  surface  of  the 
terminal  end  is  first  laid  upon  the  part. 

A  cylindrical  part  of  the  body  may  be  covered  by  a  cir- 
cular bandage,  each  turn  exactly  covering  the  previous  turns. 
A  conical  part  may  be  covered  by  a  spiral  bandage,  each  turn 
ascending  a  little  higher  than  the  previous  turn.  As  each  turn 
of  a  spiral  bandage  is  tight  at  its  upper  and  loose  at  its  lower 
edge,  the  reverse  was  devised  to  correct  this  inequality ; 
hence  a  conical  part  should  be  covered  by  a  spiral  reversed 
bandage.  To  make  a  reverse  hold  the  roller  in  the  nght 
hand,  start  the  bandage  obliquely  upward  (do  not  have 
more  than  six  inches  of  slack),  place  the  thumb  across 
the  fresh  turn,  fold  the  bandage  down  without  traction, 
and  do  not  make  traction  until  the  turn  has  been  carried 
well  around  the  limb.  A  projecting  point  is  covered  with 
figurc-of-8  turns.  The  groin,  shoulder,  breast,  or  axilla  can 
be  covered  by  figure-of-8  turns,  each  succeeding  turn  ascend- 
ing and  covering  two-thirds  of  the  previous  turn  and  form- 
ing a  figure  hke  "  the  leaves  on  an  ear  of  corn."  Such  a 
figure  is  called  a  "  spica."  In  bandaging  an  extremity  the 
peripheral  turns  should  be  tighter  than  the  turns  nearer  the 
body.  Never  apply  a  tight  bandage  to  the  leg  or  the  arm 
without  including  the  foot  or  the  hand.  In  firm  dressings 
leave  the  ends  of  the  fingers  exposed,  and  use  them  as  an 
index  of  the  condition  of  the  circulation  in  the  part. 

Spiral  Reversed  Bandage  of  the  Upper  Extremity. 
— To  apply  this  form  of  bandage  use  a  roller  two  and  a  half 
inches  wide  and  eight    yards   long.     Take  a  circular  turn 


928 


BANDAGES. 


about  the  wrist,  and  a  second  turn  to  hold  the  first ;  pass 
obHquely  across  the  back  of  the  hand  to  the  extremities  of 
the  fingers ;  ascend  the  hand  to  the  root  of  the  thumb  by 
several  spiral  turns  ;  cover  the  wrist  by  ascending  figure-of-8 
turns ;  ascend  the  forearm  by  spiral  reversed  turns ;  cover 
the  elbow  by  a  figure-of-8,  and  the  arm  by  spiral  reversed 
turns  ;  end  the  bandage  by  two  circular  turns,  and  pin  them 
together  (Fig.  345). 


Fig.  345. — Spiral  reversed  bandage  of  the  upper  extremity. 

Spiral  Bandage  of  All  the  Fingers  (Gauntlet).— The 
gauntlet  bandage  requires  a  roller  one  inch  wide  and  one 
and  a  half  yards  long.  Take  two  circular  turns  around  the 
wrist,  pass  obliquely  across  the  wrist  to  the  root  of  the  thumb, 
and  descend  to  its  tip  by  spiraL  turns  ;  cover  in  the  thumb 
by  ascending  spiral  reverses,  and  return  to  the  wrist.  Cover 
in  each  successive  finger  in  the  same  manner,  and  terminate 
by  two  circular  turns  around  the  wrist  (Fig.  346). 


Fig.  346. — Gauntlet  bandage. 


Fig.  347. — Demi-gauntlet  bandage. 


Spiral  Bandage  of  the  Palm  or  Dorsum  of  the 
Hand  (Demi-gauntlet). — The  demi-gauntlet  requires  a  roller 
one  inch  wide  and  four  yards  long. '  This  bandage  has  only 
a  limited  value ;  it  must  not  be  applied  tightly,  as  it  makes 
much  pressure  at  the  finger-roots,  but  leaves  the  fingers  free. 
If  it  is  desired  to  cover  the  palm,  supinate  the  hand  ;  if  to 
cover  the  dorsum,  pronate  the  hand.    Take  two  circular  turns 


THE    TIIL'MB. 


929 


around  the  wrist,  sweep  around  the  root  of  the  thumb,  and 
return  to  the  point  of  origin.  Treat  each  finger  in  the  same 
way.     End  bv  circular  turns  around  the  wrist  (Fig.  347). 

Spica  of  the  Thumb.— For  this  bandage  use  a  roller 
one  inch  wide  and  three  yards  long.  Start  at  the  wrist,  and 
reach  the  tip  of  the  thumb  as  in  applying  a  spiral  bandage 
of  a  finger.  Make  a  series  of  ascending  figure-of-8  turns 
between  thumb  and  wrist,  each  ascending  turn  overlymg 
two-thirds  of  the  previous  turn ;  terminate  with  a  circular  of 
the  wrist  (Fig.  348). 


Fig.  348.— Spica  of  the  thumb. 

Selva's  Thumb  Bandage  (Fig.  349).— Lay  the  terminal 
end  of  the  bandage  on  the  outer  side  of  the  second  phalanx 
of  the  thumb,  near  the  base  of  the  phalanx.     Cany  it  over 


Fig.  349.— Selva's  thumb-bandage  applied. 

the  palmar  side  of  the  pulp  of  the  last  phalanx  to  the  inner 
side  of  the  second  phalanx.  The  surgeon  holds  this  turn  in 
place  with  his  left  thumb  and  index  finger.  The  roller  is 
returned  in  a  recurrent  manner  to  its  place  of  origin,  over- 
laps the  preceding  turn,  and  is  placed  as  much  as  possible 
on  the  dorsum.  The  roller  is  carried  over  the  dorsum  of 
the  terminal  phalanx  and  is  turned  around  the  tip,  the  loop 
crossing  over  the  center  of  the  nail.  Figure-of-8  turns  are 
now  made  over  the  dorsum  of  the  hand,  over  the  palm,  and 
returning  to  the  terminal  phalanx,  and  an  ascending  spica 
is  made.^ 

Spiral  Reversed  Bandage  of  the  I,ower  Extremity. 

— Take  a  roller  two  and  a  half  inches  wide  and  seven  yards 

long,  and  make  two  circular  turns  just  above  the  malleoli, 

and  an  oblique  turn  across  the  dorsum  of  the  foot  to  the 

1  Medical  Ke-ws,  Sept.  28,  1895. 

59 


930 


BANDAGES. 


metatarsophalangeal  articulation  ;  make  a  circular  turn,  and 
cover  the  foot  with  ascending  spiral  reversed  turns  ;  return  to 
the  ankle  by  a  figure-of-8  ;  ascend  the  leg  by  spiral  reverses  ; 
cover  the  knee  by  a  figure-of-8,  and  the  thigh  by  spiral  re- 
verses ;  terminate  by  two  circular  turns  (Fig.  350). 

Bandage  of  the  Foot  covering  the  Heel  (American 
Bandage  of  the  Foot). — Take  a  roller  two  and  a  half  inches 

wide  and  seven  yards  long.  The 
bandage  is  begun  as  is  a  spiral 
reversed  bandage  of  the  lower 
extremity.  After  the  foot  is  well 
covered  by  ascending  spiral  re- 
versed turns  carry  the  bandage 
directly  around  the  point  of  the 


Fig.  350. — Spiral  reversed  bandage 
of  the  lower  extremity. 


Fig.  351. — Method  of  covering  the  heel. 


heel  and  return  to  the  instep ;  from  this  point  carry  it 
around  the  back  of  the  ankle,  down  the  side  of  the  heel, 
under  the  heel,  up  to  the  instep,  around  the  ankle  in  the 
opposite  direction,  down  the  opposite  side  of  the  heel,  and 
under  the  heel  and  up  to  the  instep ;  take  the  roller  to 
above  the  malleoli,  and  end  by  a  circular  turn  (Fig.   350- 

Bandage  of  the  Foot  not  covering  the  Heel  (French 
Method). — Take  a  roller  two  and  a  half  inches  wide  and  six 
yards  long.  Make  a  spiral  reversed  bandage  of  the  foot  and 
a  figure-of-8  of  the  ankle-joint  (Fig.  352). 

Spiral  Bandage  of  the  Foot  covering  the  Heel 
(Ribbail's  Bandage ;  Spica  of  the  Instep). — Take  a  roller 
two  and  a  half  inches  wide  and  six  yards  long.  Apply  as 
a  spiral  reversed  bandage  of  the  lower  extremity  until  the 
metatarsus  is  well  covered.  Carry  the  bandage,  parallel  with 
the  margin  of  the  foot  (the  inner  or  outer  margin,  according 
as  to  whether  it  is  the  left  foot  or  the  right),  around  the  pos- 
terior aspect  of  the  heel,  along  the  opposite  margin  of  the 
foot  to  cross  the  original  turn  at  the  median  line  of  the  dor- 


THE   EYES. 


931 


sum.  Make  a  number  of  these  ascending  turns,  each  turn 
covering  in  three-fourths  of  the  previous  turn  ;  terminate  by 
circular  turns  above  the  ankle  (F"ig.  353). 


Fig.  352.— Figure-of-8  bandage  of  the  ankle. 


Fig.  353. — Spica  of  the  instep. 


Crossed  Bandage  of  both  Byes  (Figure-of-8  of  both 
Eyes). — Take  a  roller  two  inches  wide  and  six  yards  long. 
Make  a  circular  turn  around  the  forehead  from  right  to  left, 
a  second  turn  to  hold  the  first,  a  turn  downward  over  the 
left  eye,  under  the  left  ear,  around  the  back  of  the  neck,  and 
upward  under  the  right  ear  and  over  the  right  eye  ;  repeat 
these  turns,  and  terminate  by  a  circular  turn  of  the  forehead 
(Fig.  354). 


Fig.  354. — Crossed  figure-of-8  bandage 
of  both  eyes. 


Fig.  355. — Barton's  bandage  or  figure-of-8 
of  the  jaw. 


Barton's  Bandage  (Figure-of-8  of  the  Jaw  and  Occiput). 
— Take  a  roller  two  inches  wide  and  five  yards  long.  Place 
the  initial  extremity  of  the  bandage  behind  the  inion  ;  pass 
over  the  right  parietal  bone,  across  the  vertex,  down  the  left 
side  in  front  of  the  ear,  under  the  chin,  up  the  right  side  in 


932 


BANDAGES. 


front  of  the  ear,  across  the  vertex,  and  across  the  left  parietal 
bone  to  the  point  of  origin.  A  turn  is  now  taken  forward  along 
the  right  side  of  the  jaw  to  the  chin,  and  backward  along  the 
left  side  of  the  jaw  from  the  chin  to  the  nape  of  the  neck ; 
repeat  these  turns,  and  pin  the  points  of  junction  (Fig.  355). 
In  Barton's  bandage  the  ear  lies  in  an  uncovered  triangle. 
The  bandage  may  be  finished  by  circular  turns  around  the 
forehead.  Barton's  bandage  is  used  for  fracture  of  the 
lower  jaw. 

Borsch's  eye-bandage  is  convenient  and  useful  (Fig. 
356).  A  narrow  bandage  is  laid  along  the  head  and  per- 
mitted to  hang  down  the  face  in  front  of  the  sound  eye.  A 
circular  bandage  is  applied  around  both  eyes  and  over  the 
narrow  bandage  (a).  The  narrow  strip  is  lifted  and  pinned, 
and  the  sound  eye  is  thus  uncovered.  Of  course,  the  pos- 
terior end  of  A  should  first  be  pinned  to  the  circular  turn. 


Fig.  356. — Borsch's  eye-bandage  :  A,  first  step  ;  B,  second  step. 


Gibson's  Bandage. — Take  a  roller  two  inches  wide  and 
six  yards  long.  Make  three  vertical  turns  around  the  head 
and  the  jaw  in  front  of  the  ear ;  reverse  the  bandage  above 
the  level  of  the  ear,  and  carry  it  horizontally  around  the  fore- 
head and  head  three  times ;  drop  the  bandage  to  the  nape 
of  the  neck,  and  take  three  turns  around  the  neck  and  jaw ; 
terminate  by  taking  from  the  nape  of  the  neck  a  half  turn 
upward,  carrying  the  bandage  forward  to  the  forehead,  and 
pinning  it  over  the  neck  and  over  the  forehead.  Pin  each 
point  of  junction  (Fig.  357).  Gibson's  bandage  is  used  for 
fracture  of  the  lower  jaw. 

Crossed  Bandage  of  the  Angle  of  the  Jaw  (Oblique 
Bandage  of  the  Jaw). — Take  a  roller  two  inches  wide  and  six 


THE    GROIN. 


93; 


yards  long.  Make  a  circular  turn  around  the  forehead  to- 
ward the  affected  side,  and  a  second  turn  to  hold  the  first ; 
take  the  turn  to  the  back  of  the  neck  ;  carry  it  forward  on  the 
sound  side,  under  the  ear  and  chin ;  now  make  a  series  of  turns 
around  the  head  and  jaw,  in  front  of  the  ear  on  the  injured 
side,  but  back  of  the  ear  on  the  sound  side :  these  turns 
successively  advance  on  the  sound  side  only ;  terminate  by 
going  backward  under  the  ear  of  the  sound  side  to  the  nape 
of  the  neck,  and  then  by  taking  two  circular  turns  around 


Fig.  357. — Gibson's  bandage. 


Fig.  358. — Oblique  or  crossed  bandage 
of  the  angle  of  the  jaw. 


the  forehead  (Fig.  358).  This  bandage  is  used  for  fractures 
of  the  ramus  of  the  jaw  and  for  holding  dressings  upon  the 
face  and  the  cranium. 

Spica  of  the  Groin  (Figure-of-8  of  the  Thigh  and  Pel- 
vis).— For  one  groin  the  roller  is  three  inches  wide  and  seven 
yards  long ;  for  both  groins,  three  inches  wide  and  ten  yards 
long.  Take  two  circular  turns,  from  right  to  left,  around  the 
waist,  then  down  over  the  front  of  the  right  groin,  around 
the  back  of  the  thigh,  up  over  the  front  of  the  right  groin, 
around  the  waist,  down  over  the  front  of  the  left  groin, 
around  the  back  of  the  thigh,  up  over  the  left  groin,  and 
around  the  waist.  The  map  being  thus  laid  out,  the  turns 
are  continued  and  ascended,  each  turn  overlying  one-third 
of  the  previous  turn,  and  the  bandage  is  completed  by  a 
circular  turn  around  the  waist  (Fig.  359).  Pin  the  crossed 
pieces. 

Spica  of  the  Shoulder. — Take  a  roller  two  and  a  half 
inches  wide  and  seven  yards  long.  Make  a  circular  turn 
and  several  spiral  reversed  turns  around  the  upper  arm  ;  then, 
coming  from  behind  forward,  carry  the  bandage   over  the 


934 


BAND  A  GES. 


shoulder,  across  the  front  of  the  chest,  through  the  opposite 
arm-pit,  and  return  across  the  back  to  the  shoulder.  Make 
successive  and  advancing  turns  (Fig.  360). 


Fig.  359. — Spica  of  the  groin. 


Fig.  360. — Spica  of  the  shoulder. 


Figure-of-8  bandages  of  the  elbow,  both  shoulders  (pos- 
terior figure-of-8),  the  neck  and  axilla,  and  of  the  breast 
are  shown  in  Figs.  361,  362,  363,   368. 


Fig.  361. — Figure-of-8  bandage  of  the  elbow. 


Fig. 


362. — Posterior  figure-of-8  of  both 
shoulders. 


Velpeau'S  Bandage. — Take  a  roller  two  and  a  half 
inches  wide  and  ten  yards  long.  Place  the  palm  of  the  hand 
of  the  injured  side  upon  the  shoulder  of  the  sound  side,  inter- 
posing cotton  between  the  arm  and  the  side.  Start  the  band- 
age at  the  axilla  of  the  sound  side  posteriorly,  carry  it  across 
the  back  to  the  shoulder  of  the  injured  side,  down  the  front  of 


DESA  UL  T '  .V  A  PPA  RA  TUS. 


935 


the  arm  and  under  the  arm  just  above  the  elbow,  returning  to 
the  point  of  origin ;  repeat  this  turn,  but,  on  reaching  the  axilla 
the  second  time,  cross  the  back  and  pass  around  the  chest, 
including  the  arm ;  keep  on  with  these  turns,  each  alternate 
turn  o-oing  over  the  injured  clavicle,  each  alternate  turn 
encircTing  the  arm  and  the  body,  the  first  turns  advancing 


.-UA> 


Fig.  363. — Figure-of-8  of  neck  and  axilla. 


Fig.  364. — Velpeau's  bandage. 


and  the  second  turns  ascending  (Fig.  364).     Pin  the  crossed 
pieces.     This  bandage  is  used  for  fracture  of  the  clavicle. 

Desault'S  Apparatus. — This  apparatus  consists  of  three 
rollers,  a  pad,  and  a  sling.  Each  roller  is  two  and  a  half 
inches    wide    and   seven   yards    long.      The   pad,  which  is 


Fig.  365.-Desault's  bandage,  first  roller.  Fig.  366.-Desaulfs  bandage,  second  roller. 

wedge-shaped,  is  inserted  into  the  axilla  with  the  base  up. 
The  first  roller  is  used  to  hold  the  pad  (Fig.  365).  The 
second  roller  binds  the  arm  to  the  side  over  the  pad.     This 


936 


BANDAGES. 


pad  is  a  fulcrum,  the  shoulder  is  the  weight,  the  arm  is  the 
lever,  and  the  second  roller  of  Desault  corrects  the  inward 
deformity  of  a  fractured  clavicle  (Fig.  366).  The  third 
roller  corrects  the  downward  and  forward  displacement.  It 
starts  in  the  axilla  of  the  sound  side  anteriorly,  crosses  the 
chest  to  the  shoulder  of  the  injured  side,   runs  down  the 


Fig. 


-Desault's  bandage,  third  roller 


Fig.  368. — Figure-of-8  bandage  of  the  breast. 


back  of  the  arm,  around  the  elbow,  and  crosses  the  chest 
to  the  point  of  origin,  forming  the  anterior  triangle ;  it  is 
now  carried  through  the  axilla  of  the  sound  side  to  the 
back,  crosses  the  back  to  the  shoulder  of  the  injured  side, 
runs  down  the  front  of  the  arm,  around  the  elbow,  and 
across  the  back  to  the  axilla  of  the  sound  side,  forming  the 
posterior  triangle  (Fig.  367).  The  formula  for  the  Desault 
bandage  is  :  start  in  the  axilla  of  the  sound  side  anteriorly, 
run  from  the  axilla  to  the  shoulder,  from  the  shoulder  to  the 
elbow,  from  the  elbow  to  the  axilla,  and  pass  to  the  back ; 
from  the  axilla  to  the  shoulder,  from  the  shoulder  to  the 
elbow,  from  the  elbow  to  the  axilla,  and  pass  to  the  front. 
Pin  the  crossed  pieces  and  hang  the  hand  in  a  sling  (Fig. 

367)- 

Recurrent  Bandage  of  the  Head. — Take  a  roller  two 
inches  wide  and  six  yards  long.  Make  two  circular  turns 
horizontally  around  the  forehead  and  head  ;  when  the  middle 
of  the  forehead  is  reached,  catch  the  bandage,  take  a  half 
turn,  carry  the  bandage  to  the  occiput,  let  an  assistant  catch 
it,  take  a  half  turn,  bring  the  roller  forward  to  the  forehead, 
covering  a  portion  of  the  preceding  turn  ;  continue  this  pro- 
cess until  the  scalp  is  well  covered ;  terminate  with  two  cir- 
cular turns  around  the  forehead  and  head  (Fig.  369).     It  is 


FIXED  DRESSINGS. 


937 


often   advisable  to  take  a  turn  around  the  head  and  chin. 
Pin  the  crossed  pieces. 


Fig.  369.-Recurrent  bandage  of  the  head.  Fig.   37o.-Recurrent  bandage  of  a  stump. 


Recurrent  Bandage  of  a  Stump.— Take  a  roller  two 
inches  wide  and  six  yards  long.  Make  two  light  arcular 
turns  around  the  root  of  the  stump ;  make  recurrent  turns 
covering  the  stump  as  is  done  in  covering  the  head  ;  take  a 
circular  turn  around  the  root  of  the  stump,  oblique  turns  to 
the  top  of  the  stump,  circular  turns  around  the  tip,  and 
applv  an  ascending  spiral  reversed  bandage  (Fig.   370). 

T-Bandage  of  the  Perineum.  —  Pass  the  transverse 
part  around  the  body  above  the  iliac  crests,  and  pin  it  in 
front;  bring  one  of  the  tails  over  the  dressing  and  up 
between  the  thigh  and  the  genitals  of  one  side,  and  the 
other  tail  over  the  dressing  and  up  between  the  thigh  and 
the  genitals  of  the  opposite  side ;  secure  these  tails  to  the 

horizontal  band.  ,       ,     1  r 

Handkerchief  Bandages.— Take  unbleached  muslin 
one  yard  square.  The  muslin  folded  once  makes  an  oblong 
bandage ;  bringing  its  diagonal  angles  together  makes  a 
triangle  bandage ;  a  cravat  is  formed  by  folding  a  triangle 
bandage  from  summit  to  base ;  a  cord  is  a  twisted  cravat. 
The  triangle  makes  an  admirable  sling. 

Fixed  Dressings. — Plaster-of-Paris  Bandage. — Cover 
the  extremitv  with  a  cotton  or  flannel  bandage  or  with  a 
woollen  stocking.  Take  a  gauze  roller  infiltrated  with  plaster 
and  place  it  endwise  in  a  basin  of  tepid  water,  the  water 
covering  the  plaster.  When  bubbles  cease  to  arise, 
squeeze  the  bandage  and  apply  it  ivithout  much  tension 
smoothing  out  each  turn  with  a  moistened  hand.     As  each 


938  PLASTIC  SURGERY. 

bandage  is  taken  from  the  basin  drop  a  fresh  one  into  the 
water.  Apply  four  thicknesses  of  bandage,  and  finish  the 
dressing  by  sprinkling  dry  plaster  over  the  bandage  and 
smoothing  it  with  wet  hands.  The  ordinary  plaster  will  set 
in  from  fifteen  to  thirty  minutes.  If  it  is  desired  to  have  it  set 
more  rapidly,  put  a  tablespoonful  of  salt  in  each  pint  of 
water  used;  if  to  have  it  set  more  slowly,  pour  stale  beer  into 
the  water.  The  plaster  bandage  is  removed  by  sawing  it 
down  the  front  or  by  moistening  with  dilute  hydrochloric 
acid  and  then  cutting  through  the  moistened  line  with  a  strong 
knife.  Gigli  has  devised  a  mode  of  application  which  enables 
us  to  remove  the  dressing  with  ease.  A  layer  of  cotton  is 
placed  around  the  limb.  A  piece  of  parchment  paper  which 
has  been  wet  and  shaken  out  is  placed  over  the  cotton.  A 
cord  greased  with  vaselin  is  laid  upon  the  paper  in  a  position 
corresponding  to  the  line  we  will  wish  to  saw  through  the 
plaster.  Apply  the  plaster  bandage  and  see  that  the  ends  of 
the  cord  project  beyond  the  bandage.  When  desiring  to 
remove  the  bandage  take  a  steel  wire,  make  nicks  on  one 
side  of  it  by  means  of  a  file,  and  attach  the  string  to  the 
wire.  Pull  the  wire  under  the  bandage.  Attach  each  end 
of  the  wire  to  a  wooden  handle  and  saw  through  the  plaster.^ 
Silicate-of-sodiuni  Dressing-. — Protect  the  part  as  is  done 
for  a  plaster  bandage.  Bandage  the  limb  loosely  with  an 
ordinary  gauze  bandage,  paint  this  bandage  with  silicate  of 
sodium,  apply  another  bandage  and  paint  it,  and  so  on  until 
six  layers  are  applied.  Gauze  bandages  soaked  in  silicate 
are  better  than  ordinary  bandages.  Silicate  dressings  require 
from  twelve  to  eighteen  hours  to  dry,  and  they  are  removed 
by  softening  with  warm  water  and  then  cutting. 

XXXV.  PLASTIC  SURGERY. 

Plastic  surgery  includes  operations  for  the  repair  of  de- 
ficiencies, for  the  replacement  of  lost  parts,  for  the  restora- 
tion of  function  in  parts  tied  down  by  scars,  and  for  the  cor- 
rection of  disfiguring  projections.  A  plastic  operation  can 
be  successful  after  lupus  only  when  the  disease  has  been 
cured.  It  is  useless  to  do  a  plastic  operation  during  active 
syphilis,  and  a  plastic  operation  for  a  syphilitic  loss  of  sub- 
stance is  to  be  performed  only  after  the  patient  has  been 
thoroughly  treated  and  the  disease  has  been  apparently 
cured.  The  first  step  of  a  plastic  operation  consists  in  mak- 
ing raw  the  surfaces  which  are  to  be  brought  together ;  the 

^  La  Semaine  Med.,  Nov.  3,  1895. 


SKIX-GRAFTIXG.  939 

second  step  is  the  complete  arrest  of  bleeding ;  the  third 
step  is  the  approximation  of  the  surfaces  without  tension  ; 
the  fourth  step  is  to  close  any  gap  from  which  tissue  may 
have  been  transplanted ;  and  the  final  step  is  the  application 
of  the  dressings/     The  following  are  the  methods  used:^ 

Displacement  is  the  method  of  stretching  or  of  sliding : 
(i)  approximation  after  freshening  the  edges  (as  in  hare- 
hp;  (2)  sliding  into  position  after  transferring  tension  to 
other  localities  (linear  incisions  to  allow  of  stretching  of 
the  skin  over  large  wounds).  Interpolation  is  the  method 
of  borrowing  material  from  an  adjacent  or  a  distant  region 
or  from  another  person:  (i)  transferring  a  flap  with  a 
pedicle,  which  flap  is  put  in  place  at  once  or  is  gradually 
gotten  into  place  by  a  series  of  partial  operations  (as  in 
rhinoplasty,  when  a  flap  is  transverse  from  the  forehead); 
(2)  transplanting  without  a  pedicle,  which  is  performed  by 
placing  in  position  and  by  fixing  there  portions  of  tissue 
recently  removed  from  the  part,  from  another  part  of  the 
same  individual,  or  from  a  lower  animal  (as  replacement  of 
the  button  of  bone  after  trephining,  transplanting  a  piece  of 
bone  from  a  lower  animal  to  remedy  a  bone-defect  in  a 
human  being,  or  the  grafting  of  a  piece  of  ner^-e  from  a  lower 
animal  or  an  amputated  human  limb  to  remedy  a  loss  of 
nerv^e  in  a  human  being  in  nerve-grafting,  or  skin-graft- 
ing). Retrenchment  is  the  removal  of  redundant  material 
and   the  production  of  cicatricial  contraction. 

Skin-grafting-. — In  Reverdin's  method  the  surface  to 
be  grafted  should  possess  healthy  granulations  which  are  at 
thelkin-level.  The  grafts  should',  if  possible,  come  from  the 
person  to  be  grafted. 

Grafts  may  come  from  another  person  or  from  a  lower 
animal,  but  such  grafts  are  not  apt  to  grow,  and  even 
when  thev  do  grow  fail  to  furnish  a  secure  cicatrix.  Frog- 
skin furnishes  unsati.sfactor}^  grafts.  Arnot  has  employed 
the  lining  membrane  of  a  hen's  &gg,  cut  in  strips  and 
applied  upon  the  w^ound  with  the  shell-surface  upper- 
most. Lusk  has  blistered  the  skin  with  cantharides  and 
grafted  portions  of  the  epidermis.  In  order  to  graft  sniall 
fragments  of  human  epithelium,  cleanse  the  skin  from  which 
the^ grafts  are  to  come,  the  ulcer,  and  the  skin  about  it,  and, 
if  corrosive  sublimate  is  used,  wash  it  away  with  a  stream 
of  warm  normal  salt  solution.  Thrust  a  sewing-needle 
under  the  epidermis  to  raise  it,  cut  off  the  graft  with  a  pair 
of  scissors,  and  place  the  cut  surface  of  the  graft  upon  the 

1  American  Text-book  of  Surgery.  ^  ^i-d- 


940  BANDAGES. 

ulcer.  After  applying  a  number  of  grafts,  place  thin  pieces 
of  gutta-percha  tissue  over  the  grafts  and  extending  on  each 
side  of  the  ulcer,  and  so  placed  as  to  have  distinct  inter- 
vals between  them,  the  gaps  permitting  drainage.  This  tis- 
sue, after  being  asepticized,  is  moistened  with  warm  normal 
salt  solution  {^-^  of  i  per  cent.).  Dress  with  a  pad  of  aseptic 
gauze  moistened  with  salt  solution ;  place  over  this  gauze  a 
rubber-dam,  and  over  the  latter  absorbent  cotton  and  a 
bandage.  In  the  case  of  children  apply  a  light  silicate 
bandage.  Put  the  patient  in  bed.  In  forty-eight  hours  re- 
move all  the  dressings  except  the  gutta-percha  tissue,  irri- 
gate with  normal  salt  solution,  and  reapply  the  dressings. 
All  signs  of  the  grafts  will  often  have  disappeared.  In  a 
day  or  two,  at  the  site  of  grafting,  bluish-white  spots  should 
appear,  which  are  islands  of  epidermis.  Each  graft  is  capa- 
ble of  forming  about  half  an  inch  of  cicatrix.  Grafting  also 
stimulates  the  edges  of  the  ulcer  to  cicatrize  and  contract. 
At  the  end  of  seven  days  the  special  dressings  can  be  dis- 
pensed with.  The  spot  from  which  the  grafts  are  taken  is 
dressed  antiseptically.  Reverdin's  method  does  not  limit  cica- 
tricial contraction  to  any  great  degree,  and  the  new  skin  is 
apt  to   break  down. 

Thiersch's  Method. — Thoroughly  asepticize  the  ulcer,  the 
surrounding  skin,  and  the  site  from  which  the  graft  is  to 
come  (the  inner  side  of  the  arm  or  the  thigh),  and  wash 
away  the  mercurial  preparation  with  normal  salt  solution. 
Apply  dressings  wet  with  salt  solution.  On  bringing  the 
patient  into  the  operating-room  remove  the  dressings  from 
the  ulcer,  scrape  the  ulcer  and  its  edges,  irrigate  with  salt 
solution,  and  compress  to  arrest  hemorrhage.  Grafts  are  then 
obtained  by  putting  the  prepared  skin  upon  the  stretch  and 
cutting  strips  with  a  razor.  While  the  razor  is  being  used 
the  part  is  constantly  irrigated  with  salt  solution.  Mixter's 
apparatus  enables  one  to  perform  this  operation  with  great 
neatness  and  speed.  This  apparatus  consists  of  a  knife  and 
an  open  square  with  sharp  points  on  the  under  surface.  The 
square  is  forced  down  upon  the  front  of  the  thigh,  the  epi- 
dermis mounts  up  in  the  opening  to  above  the  level  of  the 
metal  sides,  and  the  grafts  may  be  cut  with  ease.  In  Hal- 
sted's  clinic  the  skin  of  the  thigh  is  made  tense  by  pressing 
upon  it  with  a  piece  of  asepticized  wood,  the  wood  is  drawn 
slowly  along,  and  is  followed  closely  by  the  sharp  catlin, 
with  which  the  surgeon  cuts  long  grafts.  The  grafts  are 
pressed  into  place,  and  each  graft  overlaps  a  little  the  edges 
of  the  wound  and  the  adjacent  grafts.     The  skin-wound  is 


SA'/.V-GRAFT/XG. 


941 


dressed  antiseptically,  and  the  grafted  area  is  dressed  as  in 
Reverdin's  method.  Recently  it  has  been  suggested  that  a 
ring  of  aseptic  gauze  be  made  to  encircle  the  limb  below 
the  grafted  area,  and  another  ring  above  the  grafted  area ;  on 
these  pads  little  strips  of  wood  wrapped  in  aseptic  gauze  are 
so  laid  as  to  make  a  cage,  and  around  this  cage  the  dressings 
are  applied  (moist  chamber  plan). 


Fig.  371. — Mayer's  dressing  for  Thiersch's  method  of  skin-grafting  {Am.  Text-Book  of 

Surgery. 

Eo-ause's  Method. — In  this  method  the  grafts  are  com- 
posed of  the  entire  thickness  of  the  skin.  The  ulcer  is  extir- 
pated and  asepticized  and  bleeding  is  arrested.  The  flap  is 
cut  one-sixth  larger  than  the  surface  to  be  covered.  Fat  is 
kept  out  of  the  graft.  The  bit  of  tissue  is  laid  upon  the  ulcer, 
the  edges  of  the  graft  being  brought  against  the  edges  of  the 


Fig.  372. — Indian  method  of  rhinoplasty. 


Fig.  373. — Italian  method  of  rhinoplasty. 


ulcer.     It  is  not  necessary  to  employ  sutures.     The  part  is 
dressed  in  a  moist  chamber.     If  the  graft  perishes,  remove  it. 


942  DISEASES   OF  GENIT0-URIA\4RY  ORGANS. 

Rhinoplasty. — The  complete  operation  may  be  per- 
formed by  transferring  a  flap  from  the  forehead.  This  is 
known  as  the  Indian  operation.  The  edges  of  the  defect  are 
made  raw.  A  model  of  the  desired  nose  is  made  out  of  gutta- 
percha, and  its  outlines  are  marked  upon  the  forehead,  and 
the  cut  is  made  one-quarter  of  an  inch  outside  of  the  out- 
line so  as  to  allow  room  for  retraction.  The  flap  is  turned 
down  and  sutured  in  place  (Fig.  372),  care  being  taken  not 
to  cut  off  the  blood-supply  in  the  pedicle.  Plugs  of  gauze 
or  tubes  are  inserted  to  support  the  flap. 

The  complete  operation  can  be  performed  by  the  Italian 
method  (Tagliacotian  method).  In  this  method  the  flap  is 
marked  out  on  the  arm,  and  is  made  twice  the  size  of  the 
desired  nose,  and  the  flap  is  left  attached  by  a  broad  pedicle. 
The  nasal  defect  is  sewed,  and  the  flap  is  sutured  in  place, 
the  hand  being  held  upon  the  head  by  a  special  apparatus 
(Fig.  373).  The  raw  surface  upon  the  arm  is  dressed.  In 
about  three  weeks  the  flap  is  cut  loose  from  the  arm,  and  is 
pared  and  corrected  as  may  be  necessary. 

The  operations  for  harelip  and  cleft  palate,  and  plastic 
operations  on  muscles,  nerves,  tendons,  and  bones,  are 
considered  in  other  portions  of  the  work. 

XXXVI.    DISEASES   AND    INJURIES  OF  THE  QENITO= 
URINARY   ORGANS. 

Hematuria. — By  this  term  is  meant  the__yoiding_pf 
bloody  urine  or  pure  blood,  the  blood  arising  from  any  por- 
tion of  the  urinary  apparatus,  and  the  condition  being  a 
symptom  and  not  a  disease.  Hematuria  maybe  a  symptom 
of  disease  or  of  injury  of  some  part  of  the  urinary  system, 
of  blood-disorganizations  (purpurai^  scurvy^  or  variola),  or  of 
metallic  poisoning  (mercury,  lead,  or  arsenic).  The  color  of 
the  urine  in  hematuria  may  be  anything  between  a  light  red 
and  a  decided  black,  but  these  colors  may  be  produced  by 
agents  other  than  blood.  Senna  and  rhubarb  make  urine 
red ;  carbolic  and  salicylic  acids,  brown ;  beet-root  and 
sorrel,  the  color  of  blood ;  methylene-blue,  blue.  In  jaun- 
dice, melanosis,  and  splenic  fever  the  urine  becomes  brown. 
Be  sure  that  bloody  urine  in  the  female  is  not  due  to  admix- 
ture with  menstrual  blood. 

Tests  for  Blood. — Spectroscope  Test. — Fresh  urine 
diluted  with  water  shows  the  two  absorption-bands  of  oxy- 
hemoglobin. The  addition  of  ammonium  sulphid  causes 
the  two  bands  to  give  place  to  the  band  of  reduced  hemo- 


BLEEDIXG   FROM  A'/DXEY- SUB  STANCE.  943 

globin.  If  bjpody  urine  stands  for  some  time,  the  four  bands 
of  methemoglobin  are  discovered  (v.  Jaksch). 

Heller's  Test. — Add  potassium  hydrate  to  the  urine,  and 
boil :  a  red  precipitate  of  earthy  phosphates  and  hematin 
forms.  Throw  the  precipitate  upon  a  filter  and  treat  with 
acetic  acid :  a  red  solution  is  produced,  which  soon  fades. 

Rosenthal's  Test. — Take  the  precipitate  from  caustic  pot- 
ash, dry  it,  and  test  it  for  hematin  ;  put  some  of  the  dry 
sediment  on  a  slide,  add  a  crs'stal  of  common  salt,  apply  a 
cover-glass,  and  cause  a  few  drops  of  glacial  acetic  acid  to 
flow  under  the  glass  ;  warm,  but  do  not  boil.  Teichmann's 
crystals  will  appear  on  cooling. 

Struve's  Test. — Test  the  urine  with  hydrate  of  potassium, 
and  add  acetic  acid  in  excess  :  a  dark  precipitate  forms, 
which  will  yield  crystals  of  hematin  when  treated  with  sal 
ammoniac  and  glacial  acetic  acid. 

Almen's  Test. — Take  10  c.c.  of  urine,  and  pour  upon  its 
surface  a  mixture  of  equal  parts  of  tincture  of  guaiac  and 
old  oil  of  turpentine :  at  the  point  of  junction  of  this  fluid 
with  the  urine  there  forms  a  white  ring  which  turns  blue. 

Microscope  Test. — The  microscope  shows  numerous  cor- 
puscles except  in  a  ver}'  alkaline  urine,  when  but  few  cor- 
puscles may  be  found. 

In  hemoglobinuria — a  condition  sometimes  occurring  in 
burns,  acute  maladies,  and  metallic  poisoning — there  is  pres- 
ent blood-coloring  matter,  which  is  shown  by  Heller's  test 
and  by  Almen's  test.  The  spectroscope  shows  methemo- 
globin. The  microscope  shows  no  corpuscles  or  only  a  few, 
but  discloses  masses  of  pigment. 

Bleeding  from  the  Kidney-substance. — ^^Bleeding 
from  the  pelvis  of  the  kidney  and  from  the  ureter  may  be  due 
to  inflammation,  congestion,  contusion,  stone,  vicarious  men- 
struation, hemorrhagic  diathesis,  powerful  diuretics,  fevers, 
purpura,  tumors,  catheterization  of  the  bladder,  etc.  Blood 
is  thoroughly  mixed  with  the  urine,  and  no  sediment  forms 
(smoky  urine).  The__cor£uscles_are  profoundly  altered,^are 
devoid  of  coloring-matter,  and  show  pale-yellow  rings.  The 
severity  of  the  hemorrhage  is  measured  by  the  number  of 
the  corpuscles.  Von  Jaksch  states  that  the  diagnosis 
between  renal  and  ureteral  hemorrhage  rests  on  the  nature 
of  the  casts  and  the  epithelium  present.  From  the  pelvis 
of  the  kidney  and  from  the  ureter  come  small  epithelium, 
the  cells  from  the  superficial  layers  being  polygonal  or 
elliptical,  those  from  the  deeper  layers  being  oval  or  irregu- 
lar.    In  hemorrhage  from  the  ureter  the  cells  are  few :  in 


944 


DISEASES   OF  GENITO-URINARY  ORGANS. 


hemorrhage  from  the  pelvis  they  are  plentiful  and  rest  upon,, 
one  another  like  "  tiles  on  a  roof"  (v.  Jaksch).  Cells  from 
the  tubules  of  the  kidney  are  small,  granular,  and  polyhedral, 
have  large  nuclei,  and  are  often  so  arranged  as  to  form 
cylinders  (epithelial  casts).  The  urine  of  renal  hemorrhage 
is  apt  to  be  acid  unless  alkalies  have  been  administered, 
unless  the  bleeding  has  been  severe,  or  unless  pus  is  present 
in  the  urine.  A  very  large  renal  hemorrhage  may  cause  the 
passage  of  almost  pure  blood.  In  renal  hematuria  there 
are  aching  in-  the  loin,  numbness  of  the  corresponding  leg, 
and  often  renal  colic.  The  use  of  the  cystoscope  enables  the 
surgeon  to  determine  if  the  hemorrhage  is  vesical  or  jrenal, 
and  if  it  comes  from  one  or  both  kidneys.  If  the  bladder- 
fluid  is  kept  clear,  the  blood  can  be  seen  flowing  out  of  the 
ureter  of  the  damaged  organ. 

Catheterization  of  the  ureters  may  give  valuable  informa- 
tion.    Kelly  performs    this    operation  in  women    with   the 


Fig.  374. — Nitze's  instrument  in  use  (Berl.  klin.  IVochen.). 


greatest  ease.  Aseptic  precautions  are  observed.  A  specu- 
lum is  inserted,  the  orifice  of  the  ureter  is  cleansed  with  a 
bit  of  cotton,  and  the  catheter  is  inserted,  and  the  urine  is 
collected  in  a  sterile  test-tube.  Kelly's  catheter  is  of  flexible 
silk,  30  cm.  in  length,  2  mm.  in  diameter,  with  a  blunt  coni- 


BLEEDING   FROM  KIDNEY-SUBSTANCE. 


945 


cal  end  and  an  oval  eye.  The  catheter  is  pushed  into  the 
ureter  1 2  or  1 5  mm.  The  rate  of  flow  in  a  given  time  proves 
the  competence  of  the  kidney.  The  male  ureter  can  be 
catheterized  by  means  of  the  instrument  of  Nitze  (Fig.  374). 

Kelly  has  recently  catheterized  the  ureter  in  a  man  by  in- 
serting a  straight  speculum,  placing  the  patient  in  the  knee- 
chest  position  to  inflate  the  bladder  with  air,  and  introducing 
a  metalhc  catheter. 

Professor  Harris,  of  Chicago,  has  devised  an  excellent  in- 
strument (Fig.  375)  which  greatly  simplifies  the  problem  of 
obtaining  unmixed  urine  from  each  ureter.  The  double 
catheter  is  passed  into  the  bladder.  The  lever  is  inserted 
in  the  rectum  of  the  male  and  the  vagina  of  the  female. 
The  lever  is  fastened  to  the  perforated  frame  from  the  double 
catheter.  The  double  catheter  is  now  opened  in  the  bladder, 
and  the  blades  of  the  instrument  are  held  in  position  by  a 
spring.     The  end  of  the  lever  in  the  vagina  or  rectum  humps 


Fig.  375. — Harris's  instrument  fitted  for  use. 


up  the  floor  of  the  bladder  between  the  separated  ends  of  the 
divided  catheter,  and  forms  a  longitudinal  septum  or  water- 
shed between  the  ureteral  orifices.  The  end  of  each  catheter 
lies  in  the  bottom  of  a  pocket  in  the  side  of  the  water-shed. 
"  By  producing  a  very  slight  exhaustion  of  the  air  in  the  vials 
by  means  of  the  bulb,  the  urine,  as  fast  as  it  escapes  from  the 
ureters,  drops  directly  into  the  ends  of  the  catheters  and  flows 
at  once  into  the  vials,  right  and  left  respectively."  ^ 

In  using  this  instrument,  place  the  patient  flat  on  his  back 
upon  a  table,  the  thighs  and  legs  being  flexed,  and  the  feet, 
hips,  and  head  being  on  the  same  level.     Irrigate  the  bladder 


M.  I.  Harris,  in  Medicine,  April,  1S98. 


60 


946  DISEASES   OF  GENTrO-UKINARY  ORGANS. 

thoroughly  with  sterile  water,  and  have  150  c.c.  of  fluid  in 
the  bladder  when  the  blades  are  opened.  Leave  the  instru- 
ment in  place  for  thirty  minutes.  It  is  rarely  necessary  to 
give  an  anesthetic.  In  some  cases  cocaine  must  be  used, 
and  in  some  cases  of  painful  cystitis  ether  should  be  given. 
Harris  says  the  instrument  should  not  be  used  if  there  is  a 
growth  of  the  bladdder  that  bleeds  easily,  if  the  bladder  is  con- 
tracted, or  if  there  is  a  very  large  prostate  or  a  vesical  stone.^ 

Vesical  hemorrhage,  including  hemorrhage  from 
the  prostate,  may  follow  the  relief  of  retention  of  urine, 
may  be  due  to  stone,  inflammation,  tumor,  etc.,  or  may  arise 
from  traumatisms,  instrumental  or  otherwise.  The  color  of 
the  urine  is  usually  bright  red,  but  if  long  retamed  in  the 
bladder  it  becomes  black  and  often  tarry.  The  reaction  is 
alkaline.  The  clots,  when  floated  out,  are  large  and  without 
definite  shape.  In  micturition  the  urine  is  clear  or  only  a 
little  colored  at  the  beginning,  but  becomes  darker  and  darker 
as  micturition  ends,  at  which  time  the  flow  may  consist  of 
almost  pure  blood.  In  very  small  vesical  hemorrhages  the 
urine  may  be  smoky.  Crystals  of  triple  phosphate  indicate 
bladder  disorder.  The  microscope  shows  colorless  and 
swollen  corpuscles  and  many  polygonal  cells.  Symptoms 
of  bladder  mischief  usually  exist,  but  cystoscopic  examina- 
tions or  exploratory  suprapubic  cystotomy  may  be  demanded 
for  the  diagnosis. 

Urethral  Hemorrhage. — In  urethral  bleeding  blood 
comes  independently  of  micturition,  or  blood  comes  out  first 
a"h~d  is  followed  by  clear  urine.  Urethral  hemorrhage  arises 
from  an  acute  urethritis,  from  an  inflamed  stricture,  from  the 
passage  of  an  instrument,  or  from  some  other  traumatism. 

The  source  of  urethral  hemorrhage  can  be  ascertained  by 
the  use  of  the  endoscope. 

Pain  in  Genito-urinary  Diseases. — Pain  as  a  symp- 
tom of  genito-urinary  disease  may  be  found  at  some  point 
distant  from  the  seat  of  lesion.  A  stone  in  the  bladder 
causes  pain  in  the  head  of  the  penis  just  back  of  the  meatus  ; 
stone  in  the  kidney  induces  pain  in  the  loin,  the  groin,  the 
thigh,  and  the  testicle ;  inflammation  of  the  testicle  causes 
pain  in  the  line  of  the  cord  in  the  groin.  In  other  cases  of 
genito-urinary  disease  pain  is  felt  at  the  seat  of  lesion,  as  in 
urethritis  and  prostatitis.  Pain  felt  before  micturition,  and 
being  relieved  by  the  act,  is  found  in  cystitis  and  in  retention 
of  urine.  Pain  is  felt  during  micturition  in  inflammation  of 
the  bladder,  prostate,  and  urethra,  and  in  the  passage  of 

^Jour.  Ctitan.  and  Gen.-Urin.  Dis.,  May,  1899. 


FREQi'EXCV  OF  MICTURITIOX.  947 

gravel  or  stone.  Pain  which  is  acute  at  the  end  of  micturi- 
tion is  noted  in  stone  in  the  bladder,  in  inflammation  of  the 
neck  of  the  bladder,  and  in  inflammation  of  the  prostate 
gland.  The  pain  of  stone  in  the  bladder,  it  may  be  observed, 
is  ameliorated  by  rest  and  is  aggravated  by  exercise.  The 
pain  of  acute  prostatitis   is  intensified  by  defecation. 

Frequency  of  Micturition.  —  Freg^uent  mictuxition 
arises  from  irritation  of  the  sensory  nerves,  from  phimosis, 
contracted  meatus,  inflammations,  very  acid  urine,  calculi, 
urethral  stricture,  and  hyperesthesia  of  the  urethra.  Fre- 
quency_QLmLCt3Uitipn. may. be  due  to  spinal  irritability  from 
concussion  or  from  sexual  excess,  from  contraction  of  the 
bladder  rendering  the  viscus  unable  to  hold  much,  from 
worry,  anxiety,  fear,  or  from  excessive  urinary  secretion,  as 
in  diabetes  or  in  the  first  stage  of  contracted  kidney.  Fre- 
quent micturition  exists  in  obstruction  by  enlarged  prostate 
and  in  atony  of  the  bladder-walls.  Hypersecretion  of  urine 
plus  bladder  intolerance  is  known  as  "  nervousness,"  and  is 
found  in  hysteria.  Frequency  of  micturition  increased  by 
vwvcuient  is  observed  in  stone  and  tumor  of  the  bladder; 
increased  by  rest,  is  found  in  enlarged  prostate  and  atony  of 
the  muscular  walls  of  the  viscus.  Frequency  of  micturition 
wdth  diminution  of  stream-caliber  suggests  a  constriction  of 
the"  urcthral  diameter ;  frequency  of  micturition  with  dimin- 
ished force  suggests  a  posterior  stricture,  enlarged  prostate, 
or  bladder  atony.  Slowness  of  micturition  hints  at  enlarged 
prostate,  atony,  or  urethral  stricture. 

Tlioiiipsons  diagnostic  questions  are  as  follows  : 

"  I.  Have  you  any,  and,  if  so,  what,  frequency  in  passing 
water  ?  Is  frequency  more  manifest  during  the  night  or  the 
day?  Is  frequency  more  manifest  during  motion  or  rest? 
Does  any  other  circumstance  affect  it  ? 

"  2.  Is  there  pain  on  passing  urine,  and,  if  so,  is  it  before, 
during,  or  after  the  act?  What  is  its  character — acute, 
smarting,  dull,  transitory,  or  continuous  ?  What  is  its  seat  ? 
Is  it  felt  at  other  times,  and  is  it  produced  or  intensified  by 
sudden  movements  ? 

"  3.  What  is  the  character  of  the  stream  ?  Is  it  small  or 
large;  twisted  or  irregular;  strong  or  w^eak  ;  continuous,  re- 
mitting, or  intermitting  ?  Does  it  come  by  the  meatus,  or 
partly  or  entirely  through  fistulae  ? 

"4.  Is  the  character  of  the  urine  altered?  What  is  its 
appearance,  color,  odor,  reaction,  and  specific  gravity?  Is 
it  clear  or  turbid,  and,  if  turbid,  is  it  so  at  the  time  of  pass- 
ing ?     Does  it  vary  in  quantity  ?     Are  the  normal  constitu- 


948  DISEASES   OF  GENITO-URL\rARY   ORGANS. 

ents  increased  or  diminished?  Does  it  contain  abnormal 
elements,  as  albumin  or  sugar?  What  inorganic  deposits 
are  found  ?     What  organic  materials  are  met  with  ? 

"5.  Has  the  urine  ever  contained  blood?  If  so,  was 
the  color  brown  or  bright  red ;  were  the  blood  and  urine 
thoroughly  mixed ;  was  the  blood  passed  at  the  end  or  at 
the  beginning  of  micturition,  or  did  it  come  only  with  the 
last  drops  of  urine ;  or  was  it  passed  independently  of 
micturition  ? 

"  6.  Inquire  as  to  pain  in  the  back,  loins,  and  hips,  perma- 
nent or  transitory,  and  for  the  occurrence  of  severe  parox- 
ysms of  pain  in  these  regions." 

Diseases  and  Injuries  of  the  Kidney  and  Ureter. 

Tumors  of  the  Kidney. — Tumors,  innocent  or  malig- 
nant, may  arise  in  the  kidney.  Among  the  innocent  tumors 
are  fibroma,  lipoma,  angeioma,  and  adenoma.  A  malignant 
tumor  may  be  either  sarcDma  or  carjcinoma.  Sarcoma  is 
most  common  in  the  young,  and  may  reach  an  enormous 
size.  A  malignant  tumor  of  the  kidney  produces  herna- 
turia,  the  urine  often  containing  blood-casts  of  the  ureter, 
kidney,  and  pelvis  (Osier),  and  sometimes,  though  rarely, 
characteristic  cells.  Pain  is  often  present  in  the  loin  and 
thigh,, and  there  may  be^  colic-like  attacks  when  clots  are 
passing  through  the  ureter.  Emaciation  is  rapid  and  pro- 
nounced. A  tumor  can  usually  be  detected.  The  only 
possible  treatment  is  early  nephrectomy.  In  some  few 
cases  an  innocent  tumor  can  be  removed  by  a  partial  neph- 
rectomy. A  malignant  tumor  requires  a  complete  neph- 
rectomy. In  making  a  diagnosis  of  renal  tumor  use  the 
cystoscope.  If  blood  is  coming  from  a  ureter,  note  if  it  is 
from  only  one  or  from  both.  Blood  from  both  would  con- 
traindicate  nephrectomy.  Before  removing  a  kidney  it  is 
well  to  be  sure  that  the  patient  is  possessed  of  two  kidneys. 
Note  if  urine  flows  from  each  ureter,  or,  if  uncertain,  cathe- 
terize  the  ureters  or  have  a  specialist  do  it. 

Nephroptosis,  or  Mobile  Kidney. — There  are  two 
forms  of  this  condition:  (i)  movable  kidiuy,  which  is  an 
organ  freely  moving- back  of  the  peritoneum,  either  within 
the  cavity  of  its  fibrofatty  capsule  or  entirely  without  its  cap- 
sule (this  condition  is  acquired);  and  {2) floating  or  xvandcr- 
iiig  kidney,  an  organ  having  a  mesonephron  and  lying  within 
the  peritoneal  cavity  (this  rare  condition  is  always  congenital). 
Keen  states  that  there  may  be  drawn  a  clear  theoretical  dis- 
tinction between  movable  and  floating  kidney,  but  practically 


MOBILE   KIDNEY.  949 


there  is  no  rigid  line  of  demarcation,  as  a  movable  kidney 
n  av  have  as  large  a  range  of  movement  as  a  floatmg  kidney. 
W?.en Tmovable   kidnly   becomes    ^-d   -  ,-/,^;-^,^ 
situ-ition  the  organ   is  spoken  of  as  dislocated.      Ihe  organ 
mav  Zp  belovv  the  brim  of  the  pelvis,  may  cross  the  verte- 
bral   column    or  may    reach    the    anterior  abdommal    wall. 
Women  mor;  often  suffer  from  movable  kidney  t^-n  do  men 
and    it  is  found    in  the    great    majority  of  cases   upon  the 
ri<.ht  side.     Floating   kidney  is  always  congenital.     Among 
he    assicxned    causes   of  the    movable    condition    are    to   be 
amed  traumatisms,  strains,  abdominal-wall  laxity  from  preg- 
a^cy     absorption    of  peritoneal    fat    from    wasting  disease 
SoWs)  and  tight   lacing.     The  condition   is  often  asso- 
^;^^^^^A-^^^^  abdominal  viscera  (enteropto- 

^%rr^ptoC:f  Boi  Forn.s.-There  may  be  no  discomfort 
whatever,  or  the  patient  maybe  a  -nfirnjed  invalid.  ^^^^^^^ 
usual  symptoms  are  epigastric  pain  0^^\,  °  ^^^^^f;^^^^^^^^ 
middle  line),  which  disappears  when  the  ^  ^n^y  ^    eP^^ 
drao-cing  pain  in  the  loin,  and  paroxysms  ^^^^     P       InH  the 
TheTe  is^^sense  of  a  moving  body  m  the  abdomen,  and  the 
patient  has    aggravated  indigestion,  often   accomp-^^^^^  by 
vomiting.     Constipation  is  the  rule,  and  violent  flacks  oi 
rdiac^palpitatio^    are    common.      Most    -bject^  ^J  ^^;- 
kidnev-mobility  are  extremely  nervous,  many  of  them  nys 
^ericaf  ^hypochondriacal     In  women  the  sexual  organs 
are  almost  invariably  deranged,  and  menstruation  aggravates 
?he  paTn  and  discomfort.     All  the  symptoms  are  intensified 
byex  rtion  and  are  modified  by  rest^    The  -nne  is  norn^al 
The  proof  of  the  existence  of  movable  kidney  is  the  finding 
If  a  Cor  (movable  on  respiiajion,  change  of  position   and 
mbation)  shaped  like  that  organ,  pressure  upon  which  oc- 
?^S"?o  sensation  or  causes  pain  or  a  sickerimg  feelmg. 
T'  lumbar  recess-'  (Morris)  maybe  ^und,  and  percussKm 
over  the  loin   gives  resonance.     In  some  cases  a  movable 
kS^an-be  Veadily  detected  when  the  Pat-t  st-^cls  u^^^ 
but  is  hard  to  find  when  he  is  recumbent.     F  anks  s  method 
of  examination  is  very  satisfactory.     The  patient  is  placed 
recumbent.     If   dealing  with    a    right    kidney,  the    surgeon 
standi  to  the  right  side  and  pushes  four  fingers  of  his  left 
hand   n  the  loin^elow  the  twelfth  rib,  and  rests  the  thumb 
hthtly  in  front  just  below  the  ribs.     The  patient  takes  a  ful 
b?eath  and  holds  it  a  moment,  and  just  before  he  empties 
h  s  lun-s  tl  e  surgeon  presses  his  thumb  up  deeply  below 
t  ribY  SSring^xpir^tion   the  thun.b  follows  the     ver 
and  the  fingers  press  toward  the  front.     If  with  the  ri.nt 


950  D/SEASES   OF  GENITO-URIXARY   ORGANS. 

hand  the  kidney  can  be  feh  entirely  below  the  left  hand,  the 
case  is  one  of  movable  kidney.  If  such  a  condition  is  de- 
tected, press  hard  with  the  right  hand,  and  gradually  loosen 
the  grasp  of  the  left  hand,  and  the  kidney  will  slip  between 
the  fingers  and  ascend.  A  normally  mobile  kidney  descends 
so  that  its  lower  half  can  be  felt,  but  it  moves  back  during 
expiration.^  A  movable  kidney  must  not  be  mistaken  for 
a  distended  gall-bladder,  a  tumor  of  the  mesentery,  stomach, 
or  omentum,  a  phantom  tumor,  an  ovarian  tumor,  or  a  can- 
cer of  the  pancreas.  Sometimes  a  movable  kidney  endan- 
gers life,  rupture  of  the  kidney  or  twisting  or  rupture  of  the 
ureter  occurring,  the  ultimate  cause  of  death  being  albumi- 
nuria, uremia,  or  hydronephrosis. 

Treatment. — Mobile  kidney  is  treated  as  follows:  (i)  TJie 
rest-treatment  of  Weir  Mitchell  may  be  tried ;  it  often  markedly 
mitigates  the  symptoms,  but  does  not  seem  to  cure.  (2) 
Bandage  and  pad  should  always  be  tried,  using  the  pad  of 
Dunning  or  Newman :  this  will  cure  not  a  few  cases. 
Edebohls  uses  only  a  bandage  of  elastic  webbing  or  a  w^ell- 
fitting  corset.  (3)  NeplirorrhapJiy  or  nephropexy  is  the 
operation  employed  in  many  instances  (page  963).  It  is  the 
author's  experience  that  if  the  patient  has  had  marked 
nervous  symptoms  for  a  long  time,  nephrorrhaphy  will  rarely 
cause  them  to  permanently  pass  away,  even  though  the  kid- 
ney remains  firmly  anchored.  (4)  Nephrectomy  is  necessary 
only  in  very  rare  cases  ;  it  may  be  done  for  dislocated  kidney, 
when  kidney  disease  exists,  or  when  nephrorrhaphy  has  failed 
in  a  case  of  great  sev^erity. 

Injuries  of  the  Kidney. — Laceration  or  rupture  is 
caused  by  falls  and  by  blows  upon  the  back  or  the  belly. 
The  blood  may  or  may  not  extravasate  into  surrounding 
structures.  The  symptoms  are  pain  in  the  loin,  shooting 
into  the  testicle  or  the  thigh  ;  frequent  and  painful  passage 
of  bloody  urine  or  suppression  of  urine ;  the  loin  is  full  and 
is  dull  on  percussion,  and  collapse  or  evidences  of  internal 
hemorrhage  exist.  Bloody  urine  is  not  proof  of  renal  injury, 
and  kidney  damage  may  occur  without  hematuria.  The  use 
of  the  cystoscope  or  catheterization  of  the  ureters  will  show 
from  which  kidney  blood  comes. 

Treatment. — If  the  shock  is  profound  with  increasing  ful- 
ness of  the  loin,  whether  hematuria  exists  or  not,  or  if  blood 
comes  profusely  from  the  urethra,  make  an  exploratory 
lumbar  incision  and  stop  the  bleeding  by  packing,  or  by  a 
purse-string  suture  (Figs.  376,  377),  or,  if  necessary,  perform 
partial,  or  even  complete,  nephrectomy.    Ordinarily  the  cases 

1  British  Med.  Journ.,  Oct.  12,  1895. 


WOUNDS   OF   THE   KIDNE\.  95 1 

are  treated  by  rest  in  bed  and  by  feeding  with  liquid  food  or  by 
nutritive  enemata  to  prevent  vomiting.  Opium,  tannic  acid,  or 
gallic  acid  may  be  used.    Apply  ice-bags  to  the  loin  and  the 


Fig.  376.—"  Purse-string"  suture  applied  to  a  perforation  (after  Schachner). 


side  of  the  abdomen,  and  after  bleeding  ceases  strap  the  loin 
and  apply  a  binder.  If  large  blood-clots  cause  pain  or  reten- 
tion, introduce  a  catheter  and  inject  the  bladder  with  boric 


Fig.   377— Showing  the  application  of  a   double  "purse-string"  suture   for  the   arrest   of 
hemorrhage  in  large  wound  (after  Schachner). 

acid,  or  use  the  tube  and  evacuator  of  a  Bigelow  apparatus. 
If  this  procedure  fails,  open  the  bladder  by  a  suprapubic 
incision  and  drain. 

Perforating  wounds  of  the  kidney,  if  purely  posterior,  do 
not  involve  the  peritoneum  ;  if  anterior,  they  do.  The  symp- 
toms are  escape  of  blood  and  urine  by  the  wound;  hematuria 
is  usual,  but  not  invariable ;  pain  as  in  rupture ;  the  patient 
may  be  unable  to  micturate  ;  and  nausea,  vomiting,  and  con- 
stitutional signs  of  hemorrhage  exist.  Traumatic  peritonitis, 
perinephric  abscess,  or  general  sepsis  may  ensue.     Confirm 


952  DISEASES   OF  GENITO-URINARY   ORGANS. 

the  diagnosis  by  exploration  with  the  finger.  Extraperi- 
toneal injuries  give  a  good,  and  intraperitoneal  a  bad, 
prognosis. 

TrcaUnent. — If  the  wound  in  perforated  kidney  is  extra- 
peritoneal, enlarge  it  to  permit  of  drainage,  and  arrest  hem- 
orrhage by  packing  and  hot  water,  or  by  a  purse-string  suture 
(Figs.  376,  377).  Asepticize  the  wound,  insert  a  drainage- 
tube  down  to  the  kidney,  dress  often  with  bichlorid  gauze, 
keep  the  patient  in  bed  on  a  low  diet,  and  give  gallic  acid 
and  opium.  In  some  cases  nephrectomy,  partial  or  complete, 
will  be  required.  In  intraperitoneal  waunds  perform  an 
abdominal  section  and  remove  the  damaged  organ  (see 
Nephrectomy). 

Wounds  of  the  Ureter. — The  ureter  may  be  wounded 
by  the  surgeon  accidentally  during  the  performance  of  an 
abdominal  operation,  or  it  may  be  wounded  intentionally,  as 
in  Morris's  cases,  in  which  a  malignant  growth  was  incorpo- 
rated with  the  ureter.  Wounds  of  the  ureter  as  a  result  of 
accidental  violence  are  almost  invariably  associated  with  other 
serious  injuries. 

Treatment. — Remember  that  the  upper  three-fourths  of 
the  ureter  can  be  reached  by  an  extraperitoneal  incision, 
which  is  a  prolongation  of  the  incision  for  lumbar  nephrec- 
tomy, running  from  the  twelfth  rib  downward,  and  forward 
to  one  inch  anterior  to  the  spine  of  the  ilium,  and  then 
parallel  to  Poupart's  ligament  until  a  point  is  reached  above 
its  middle  (Fenger).  The  lower  one-fourth  of  the  ureter  can 
be  reached  by  abdominal  section  or  by  sacral  resection 
(Cabot).  If  it  seems  probable  that  the  ureter  is  wounded  or 
ruptured  explore,  and  if  this  is  found  to  be  the  case  en- 
deavor to  restore  the  continuity  of  the  tube  (Fenger).  If  the 
ureter  is  cut  across  near  the  bladder,  implant  the  proximal 
end  into  the  bladder  (Van  Hook,  Penrose,  Kelly).  If  it  is 
cut  above  the  bladder  portion,  perform  lateral  implantation 
by  Van  Hook's  method  (page  965). 

A  longitudinal  wound  of  the  urethra  inflicted  during  an 
abdominal  operation  should  be  sutured,  but  if  the  duct  can- 
not be  readily  reached,  simply  make  a  posterior  incision  and 
drain,  as  the  longitudinal  wound  will  heal  by  granulation  if 
no  sutures  are  inserted  (Van  Hook). 

Renal  Calculus. — A  stone  in  the  kidney  is  formed  by 
the  precipitation  of  urinaiy  salts  into  the  renal  epithelial  cells 
and  the  gluing  together  of  these  salts  and  cells  by  material 
from  mucus  or  blood-clot,  this  mass  serving  as  a  nucleus 
on  which  accretion  takes  place.     Most  calculi  escape  when 


STOXE    IX   THE   KWA'E\.  953 

small  as  ^-/v/rr/.  The  cause  is  a  highly  acid  urine,  which 
induces  catarrh  of  the  renal  tubes.  This  high  concentration 
of  urine  is  favored  by  a  sedentary  life,  by  the  ingestion  of 
much  alcohol  or  nitrogenous  food,  by  constipation,  by  an 
inactive  skin,  and  by  a  torpid  liver.  The  children  of  poverty 
are  liable  to  calculi  because  of  the  use  of  unsuitable  foods 
and  the  formation  of  great  amounts  of  nitrogenous  waste. 
Males  more  often  suffer  than  do  females,  certain  locations 
favor  the  development  of  the  malady,  and  a  family  tendency 
sometimes  exists. 

Symptoms.— The  symptoms  of  stone  .in  the  kidney  may 
not  appear  for  years,  but  generally  they  are  manifested  early. 
The  patient  usuallv  complains  of  pain  in  the  loin,  and  some- 
times of  pain  in  the  iliac  region.     Deep  percussion  over  the 
kidney  causes  pain  in  the  loin,  even  when  pressure  is  pain- 
less (Jordan  Llovd's  symptom).    Pain  is  aggravated  by  exer- 
cise      The  urine  is  often   somewhat   albuminous,  and  may 
from  time  to  time  contain  blood.    Frequency  of  micturition  is 
noted  during  the  day,  but  not  at  night.     The  urine  may  be 
purulent.    Nephritic  colic  is  due  to  the  washing  of  a  calculus 
into  the  orifice  of  the  ureter,  which  it  blocks,  tears,  or  dis- 
tends. The  pain  is  either  sudden  or  gradual  in  onset,  is  fearful 
in  intensity,  and  runs  from  the  lumbar  region  down  the  cor- 
responding  thigh   and    spermatic    cord  (the    testicle   being 
retracted)  and  into  the  abdomen  and  shoulder-blade.     There 
are  nausea,  vomiting,  collapse,  sometimes  unconsciousness  or 
convulsions.     Frequent  attempts  at  making  water  are  pro- 
ductive of  pain,  but  of  little  urine.     The  urine  is  usually,  but 
not  always,  smoky  from   blood.      After   a   time   the   pain 
vanishes,  the  stone  having  passed  into  the  bladder  or  having 
fallen  back  into  the  pelvis  of  the  kidney.    A  calculus  retained 
in  the  kidney  eventually  excites  pyelitis.     There  is  pus  in 
the  urine,  and   soreness  or  pain  in  the   loin  exists.     Kelly 
says :  even  if  pus   is   found  we   are   not   always   sure  from 
which   kidney  it  came.     Pain  or  swelUng  may  point  to  one 
side,  but  we  are  not  sure  that  the  other  organ  is  not  also 
affected.     If  able  to  pass  the  renal  catheter  into  one  ureter, 
attach  a  syringe,  and  by  making  suction  draw  out  any  pus 
which  may  be  present.     In  renal  calcuh  cases  this  fluid  is 
apt  to  contain  fragments   of  uric   acid.     By  using   a   renal 
bougie  coated  with  dental  wax  it  may  be  possible  to  make 
scratches  on  the  instrument  when  it  comes  in  contact  with  a 
concretion.'     Slight  attacks  of  colic  occur  from  the  passage 
of  small  stones  or  of  plugs  of  mucus.     When  a  stone  is  im- 

1  Howard  Kelly,  in  Med.  News,  Nov.  30,  1895. 


954  DISEASES   OF  GENITO-UKINARY  ORGANS. 

pacted  in  the  pelvis  the  point  of  greatest  tenderness  on  press- 
ure is  below  the  last  rib,  by  the  edge  of  the  erector  spinae 
muscle.  When  a  stone  is  impacted  in  the  ureter  the  point  of 
greatest  tenderness  is  either  in  the  loin  below  the  level  of  the 
kidney  or  in  the  iliac  region  (Perkins).  In  many  cases  a 
stone  in  the  kidney  or  ureter  can  be  skiagraphed.  If  a 
stone  partly  obstructs  the  ureter,  the  urine  is  pale  and  of 
low  specific  gravity  and  free  from  albumin.  Jordan  Lloyd 
says  that  impaction  near  the  bladder  causes  symptoms  sim- 
ilar to  stone  in  the  bladder.  Impaction  near  the  kidney  is 
accompanied  by  hematuria  and  pyuria.  In  stone  in  the 
ureter  prodding  the  loin  does  not  cause  pain  (Lloyd). 
Entire  obstruction  of  the  ureter  induces  hydronephrosis  or 
pyonephrosis.  Nephrolithiasis  may  cause  death  by  ex- 
haustion, by  sepsis,  by  rupture  of  a  hydronephrosis,  or  by 
amyloid  degeneration. 

Treatment. — For  the  gravel  of  the  uric-acid  diathesis  use. 
alkalies,  especially  the  liquor  potassii  citratis,  and  reduce  the 
amount  of  nitrogen  in  the  diet  to  a  minimum,  at  the  same 
time  washing  out  the  organs  by  copious  draughts  of  Poland 
water  or  Londonderry  lithia.  Piperazin,  in  doses  of  gr. 
V  to  gr.  viij  three  times  a  day,  is  highly  commended.  Exer- 
cise is  to  be  insisted  on.  When  gravel  is  phosphatic  order 
strychnin,  the  mineral  acids,  and  rest  at  the  seaside.  When 
oxalate  of  lime  is  found  restrict  diet,  use  the  mineral  acids, 
recommend  travel  or  rest  amid  new  surroundings,  and  give 
an  occasional  course  of  sodii  phosphas,  .^ss  three  times  a  day, 
drunk  in  Buffalo  lithia  water.  Nephritic  colic  is  relieved  by 
hypodermatic  injection  of  morphin  and  atropin,  the  hot  bath, 
diluent  drinks,  or  the  inhalation  of  ether.  After  the  attack 
wash  out  the  bladder  with  an  evacuator.  If  a  stone  impacts 
in  the  ureter,  perform  the  operation  of  ureterolithotomy. 
The  diagnosis  of  this  impaction  is  often  possible  only  by 
exploratory  laparotomy.  If  the  symptoms  point  to  stone  in 
the  kidney,  medical  treatment  having  been  used  without 
avail,  and  there  being  no  evidence  of  organic  disease  of  the 
other  kidney,  make  an  exploratory  lumbar  incision  ;  feel  the 
surface  of  the  kidney  with  the  finger,  sound  the  inside  of  the 
organ  with  a  needle,  and  if  a  stone  is  detected,  incise  the 
kidney  and  remove  the  stone.  Keen  is  of  the  opinion  that 
operation  should  not  be  performed  if  the  urea  is  below  i  per 
cent.  If,  after  nephrolithotomy,  suppression  of  urine  occurs, 
cut  into  the  other  kidney,  as  in  half  of  all  cases  a  stone  will 
be  found  lodged  there. 

Abscess  of  the  kidney  is  caused  by  traumatism,  by 


PERINEPHRITIS.  955 

calculus,  by  stricture  of  the  urethra,  by  disease  of  the  blad- 
der, by  the  union  of  miliary  abscesses,  or  by  pyemia. 

The  symptoms  are  pus  in  the  urine  (this  is  usual,  but 
not  invariable),  hematuria  jn  traumatic  cases,  and  pain  run- 
ning into_tlLe^rQiii-  The  urine  is  usually  alkaline.  Consti- 
"tultlonal  symptoms  of  suppuration  exist,  the  fever  being  far 
higherthan  that  usually  met  with  in  renal  tuberculosis. 
The  bladder  should  be  examined  with  a  cy.stoscopeTo  deter- 
mine that  the  turbid  urine  flows  from  a  ureter  and  to  identify 
the  diseased  side.  It  is  well,  if  possible,  to  catheterize  the 
ureters. 

The  treatment  in  the  early  stage  is  rest,  morphin,  purga- 
tion, anodynes,  and  ice-bags  to  the  loin,  followed  in  fort}*- 
eight  hours  by  hot  fomentations.  When  the  diagnosis  is 
clear  incise  the  loin,  open  and  stitch  the  kidney  to  the  ab- 
dominal wall,  or,  if  the  organ  be  badly  damaged,  remove  it. 

Pyelitis  and  pyelonephritis,  which  usually  affect  only 
one  gland,  are  caused  by  urethral  stricture,  by  stopping  of 
the  ureter  b}"  blood-clot,  by  vesical  paralysis,  by  stone  in  the 
bladder  or  in  the  kidne}-,  and  by  enlargement  of  the  prostate 
gland. 

Symptoms. — A  patient  who  has,  or  who  has  had,  reten- 
tion of  urine  develops  high  fever,  often  preceded  by  a  chill ; 
headache,  stupor,  and  ^xy  tongue  are  noted.  Unlike  acute 
Bright's  disease,  there  is  neither  edema  nor  dr}^  skin,  con- 
vulsions do  not  occur,  and  the  urine  is  plentiful  and  contains 
pus  and,  but  rarely,  blood.     The  prognosis  is  very  bad. 

The  treatment  is  to  remove  the  obstruction  if  possible. 
If  the  urine  be  acid,  give  liquor  potassii  citratis  ;  if  alkaline, 
give  benzoic  acid.  Gallic  acid,  eucah'ptol,  and  small  doses 
of  copaiba  or  cubebs  are  recommended.  \^enice  turpentine, 
camphor,  and  opium  may  be  given  in  pill-form.  Quinin  is 
used  to  stimulate  the  patient  and  to  lower  fever.  The  bladder 
is  to  be  washed  out  every  day  with  boric-acid  solution  (gr. 
iij-gj).  Cups,  dr\"  or  moist,  and  hot  sand-bags  or  bran-bags 
are  to  be  applied  to  the  loin.  Alcohol  may  be  sparingly 
administered.     Urotropin  has  lateh'  been  used  with  benefit. 

Perinephritis  is  an  inflammation  of  the  perinephric  fatty 
tissue  produced  by  cold,  febrile  disease,  slight  traumatism, 
or  spread  of  inflammation  from  another  part. 

The  symptoms  of  this  condition  are  rigidit}*  of  the  spine, 
the  inclination  being  toward  the  affected  side,  flexion  of  the 
thigh,  and  often  pain  in  the  knee.  The  symptoms  resemble 
those  of  hip-joint  disease  in  the  second  stage.  Suppuration 
may  or  may  not  take  place. 


956  DISEASES   OF  GENITO-UREYARY  ORGANS. 

The  treatment  is  wet  cups  to  the  loin,  ice-bags  to  the  loin, 
rest,  purgation  by  salines,  morphin  for  pain,  and,  after  the 
acute  stage,  potassium  iodid  internally  and  ichthyol  locally. 

Perinephric  Abscesses. — An  abscess  in  the  perinephric 
fat  is  known  as  a  perinephric  or  perirenal  abscess.  Primary 
abscess  is  caused  by  chills,  acute  febrile  disturbances,  or  by 
pus  flowing  from  some  other  part,  as  the  spine.  Slight 
traumatisms  by  producing  hemorrhage  make  the  peri- 
nephric region  a  point  of  least  resistance,  and  lead  to 
abscess.  The  causative  injury  may  be  produced  by  dig- 
ging, stamping,  coughing,  falling,  carrying  a  burden,  lifting 
a  weight,  riding  on  a  horse  or  in  a  jolting  wagon.  Consecu- 
tive abscess  is  secondary  to  kidney  inflammation,  suppura- 
tion, calculus,  tuberculosis,  or  cyst.  In  the  consecutive  form 
the  symptoms  may  be  masked  by  the  malady  to  which  peri- 
nephric abscess  is  secondary.  As  a  rule,  in  perinephric 
abscess  there  are  found  the  constitutional  symptoms  of 
suppuration.  The  local  symptoms  are  a  deep  aching  and 
paroxysmal  pain  intensified  by  lumbar  pressure.  Edema  of 
the  corresponding  foot  and  lameness  are  not  unusual.  The 
thigh  is  often  drawn  up.  Edema  of  the  skin  is  usual,  but 
fluctuation  is  rare.  The  exploratory  incision  will  settle  a 
doubtful  diagnosis. 

The  treatment  is  to  lay  open  the  abscess,  wash  it  out, 
and  drain. 

Hydronephrosis  is  a  condition  of  the  kidney  in  which 
an  impediment  to  the  outflow  of  urine  is  caused  by  obstruc- 
tion in  the  ureter,  the  bladder,  or  the  urethra,  the  calyces  of 
the  kidney  becoming  over-distended  with  urine  and  the  gland- 
ular tissue  being  absorbed  by  pressure.  It  has  been  asserted 
by  Albanan  that  secretion  of  urine  ceases  in  a  kidney  whose 
ureter  is  blocked,  distention  being  due  purely  to  congestion. 
This  condition  may  be  congenital,  due  usually  to  twisting 
of  the  ureter  or  to  valve-formation  obstructing  the  ureter 
at  its  point  of  junction  with  the  pelvis  of  the  kidney,  the 
valve  being  produced  because  the  ureter  passes  into  the 
kidney  pelvis  at  an  unnatural  angle.  Occasionally  imper- 
forate meatus  produces  hydronephrosis  of  both  kidneys. 
The  causes  of  the  acquired  form  are  the  pressure  of  pelvic 
growths  or  pregnancy,  inflammation  or  tumor  of  the  blad- 
der, stone  in  the  bladder,  kidney,  or  ureter,  twisting  or  kink- 
ing of  the  ureter  of  a  movable  kidney,  enlargement  of  the 
prostate  gland,  and  stricture  of  the  urethra.  This  acquired 
hydronephrosis  may  involve  both  kidneys,  all  of  one  kid- 
ney, or  only  a  part  of  a  single  gland. 


P  YONEPHR  OS  IS.  957 

Symptoms. — Hydronephrosis  is  most  frequent  in  females. 
When  tumor  is  absent  there  may  be  no  symptoms,  or  there 
may  be  pain  in  the  back  and  abdomen,  frequent  micturition, 
a  persistent  or  intermittent  diminution  in  urine,  or  even  occa- 
sional anuria.  A  tumor  may  be  found  in  the  loin,  which 
growth  is  dull  on  percussion  and  may  come  and  go,  a  large 
urinary  flow  occasionally  occurring  when  it  disappears.  Hy- 
dronephrosis may  last  a  long  while  if  only  one  kidney  be 
involved,  but  death  is  not  far  distant  if  both  glands  suffer. 
Death  occurs  from  anemia,  from  pressure  on  adjacent  organs, 
or  from  rupture  into  the  peritoneal  cavity.  The  diagnosis  is 
aided  by  the  use  of  the  cystoscope  and  by  catheterizing  the 
ureters. 

Treatment  by  aspiration  may  cure,  but  the  operation  may 
have  to  be  done  repeatedly.  Tapping  on  the  left  side  is 
performed  just  below  the  last  intercostal  space  ;  on  the  right 
side  the  tap  is  made  midway  between  the  last  rib  and  the 
crest  of  the  ilium.  Some  few  cases  have  been  cured  by 
catheterizing  the  ureter  (Pawlik).  The  proper  operation  in 
most  cases  is  nephrotomy,  stitching  the  edges  of  the  cut 
kidney  to  the  surface.  After  the  kidney  has  been  opened 
explore  the  ureter  by  means  of  a  uterine  sound  or  an  elastic 
bougie.  A  healthy  ureter  wall  permit  the  passage  of  an 
instrument  of  the  size  of  from  No.  9  to  12  (Fenger).  If  the 
opening  of  the  ureter  into  the  pelvis  cannot  be  found,  open 
the  pelvis  or  open  the  ureter.  A  valve  is  slit  longitudinally 
(Fenger).  If  a  permanent  suppurating  fistula  ensues  or  if 
the  organ  is  found  extensively  damaged,  nephrectomy  is  to 
be  performed,  provided  the  other  kidney  is  in  reasonably 
good  condition. 

Pyonephrosis,  or  surgical  kidney,  is  a  condition  in 
w^hich  the  pelvis  and  the  calyces  of  the  kidney  are  distended 
with  pus  or  with  pus  and  urine.  The  whole  kidney  may 
be  destroyed.  This  condition  has  the  same  causes  as 
has  hydronephrosis,  for  it  is  in  reality  usually  an  infected 
hydronephrosis.  In  some  cases  the  inaugural  malady 
is  pyelitis,  which  causes  blocking  of  a  ureter.  Watson  of 
Boston  has  reported  two  cases  associated  with  obliteration 
of  the  ureter  by  a  mass  of  fibrous  tissue  (stricture  of  the 
ureter). 

Symptoms. — At  first  the  symptoms  are  those  due  to  the 
obstructing  cause,  plus  pyelitis.  Pus  may  appear  in  the 
urine  in  incomplete  obstruction,  or  it  may  intermittently 
come  and  go.  Constitutional  symptoms  of  suppuration  are 
soon  manifest.     A  tumor  may  appear  in  the  loin,  like  the 


958  DISEASES   OF  GENITO-URINARY  ORGANS. 

tumor  of  hydronephrosis.  If  only  one  kidney  is  involved, 
and  if  the  disease  is  due  to  blocking  of  a  ureter,  recovery 
is  to  be  expected.  The  diagnosis  is  rendered  more  cer- 
tain by  the  use  of  the  cystoscope  and  by  catheterizing  the 
ureters. 

The  treatment  in  the  early  stages  comprises  removal,  if 
possible,  of  the  cause  of  obstruction  and  the  employment  of 
measures  directed  to  the  cure  of  the  pyelitis.  If  obstruction 
is  not  complete,  palliative  measures  may  be  employed  for 
the  tumor.  If  fever  is  continued,  if  there  is  great  visceral 
derangement,  if  pain  is  severe  and  constant,  and  if  the  tumor 
continually  grows,  perform  a  nephrotomy,  stitching  the  organ 
to  the  surface  if  possible,  or  removing  it  if  it  is  hopelessly 
disorganized. 

Chronic  Tuberculosis  of  the  Kidney. — This  condi- 
tion may  begin  in  one  kidney,  no  other  depot  of  infection 
existing  in  the  body.  In  such  cases  the  organisms  were 
deposited  from  the  blood.  The  other  kidney  is  usually 
involved  subsequently,  the  process  in  the  first  kidney  affect- 
ing the  bladder  and  secondarily  the  other  kidney.  The 
important  point  is  that  tuberculosis  of  the  kidney  arising  in 
this  manner  is  at  first  a  unilateral  disease. 

Tuberculosis  of  the  kidney  may  arise  secondarily  to  tuber- 
culosis of  the  prostate  and  bladder.  In  such  a  condition  the 
kidney  disease  is  usually  bilateral. 

Symptoms. — Renal  tuberculosis  of  arterial  origin  may  ex- 
hibit no  symptoms  until  the  disease  is  far  advanced.  Renal 
tuberculosis  secondary  to  disease  of  the  bladder  or  prostate 
always  presents  symptoms.^  A  very  common  symptom  is 
the  sudden  onset  of  polyuria  and  frequent  micturition.  The 
patient  is  annoyed  day  and  night,  and  in  some  cases  mic- 
turition is  distinctly  painful.  Paroxysms  of  renal  pain  are 
not  unusual.  The  urine  is  acid,  and  may  contain  pus  or 
blood.  Tubercle  bacilli  may  be  found  in  the  urine  or  in 
the  sediment,  but  they  may  be  absent.  Repeated  examina- 
tions should  be  made  before  it  can  be  stated  certainly  that 
bacilli  are  absent.  The  presence  of  bacilli  proves  the  diag- 
nosis, but  their  absence  does  not  negative  it  (Willy  Meyer). 
If  bacilli  are  not  found,  inject  some  of  the  urinary  sediment 
into  a  guinea-pig,  and  note  if  tuberculosis  arises  in  the 
animal.     The  urine  may  or  may  not  be  albuminous. 

Czerny  has  shown  that  in  cases  of  tubercular  kidney  in 
which  bacilli  are  not  found  in  the  urine,  the  administration 
of  tuberculin  will  cause  great  numbers  to  appear.  This  agent 

1  F.  Tilden  Brown,  New  York  Med.  Jour.,  April  lo,  1897. 


NEPHROTOMY.  959 

will  also  cause  a  marked  febrile  reaction  if  tuberculosis  exists. 
In  spite  of  the  important  diagnostic  result  of  a  dose  of  tuber- 
culin it  is  scarcely  wise  to  give  it,  as  it  may  cause  dissemi- 
nated tuberculosis. 

In  many  cases  the  kidney  is  obviously  enlarged,  and  this 
area  is  frequently  tender  and  occasionally  painful.  The 
patient  loses  flesh,  and  there  is  nocturnal  fever  followed  by 
sweating.  The  use  of  the  cystoscope  furnishes  important 
information.  It  shows  from  which  ureter  turbid  urine  is  com- 
ing. Catheterization  of  the  ureters  should  be  practised  by 
some  one  who  is  accustomed  to  employ  it.  Always  examine 
carefully  to  determine  if  one  or  both  kidneys  are  involved, 
if  the  bladder  is  diseased,  and  if  the  prostate  gland  or  semi- 
nal vesicles  are  tubercular. 

Treatment. — Nephrectomy  is  not  justifiable  in  the  very 
beginning  of  a  case,  because  such  a  case  may  attain  to  a 
cure  by  a  combination  of  medical  and  hygienic  treatment, 
and  the  w^eakening  effect  of  the  operation  of  nephrectomy  may 
cause  the  other  kidney  to  rapidly  develop  tuberculosis.  Tell 
such  a  patient  to  lead  an  outdoor  Hfe.  Brown  recommends 
camp-life  in  the  Adirondacks  during  the  summer,  and  sends 
such  patients  south  during  the  winter.  If  a  patient  cannot  go 
to  another  climate,  urge  upon  him  the  necessity  of  being  much 
out  of  doors.  Insist  upon  the  taking  of  plenty  of  nutritious 
food.     Order  courses  of  creasote  or  guaiacol  carbonate. 

If  the  kidney  is  markedly  enlarged,  if  there  is  profuse 
hematuria,  if  the  fever  is  high  and  persistent,  if  only  one 
kidney  is  involved,  and  if  the  bladder  and  prostate  are  free 
from  disease,  perform  nephrectomy.  In  cases  with  involve- 
ment of  the  other  kidney  or  of  the  genito-urinary  tract  lower 
down,  nephrectomy  is  rarely  justifiable,  although  nephrot- 
omy for  drainage  may  greatly  benefit  the  patient  for  a 
time. 

Operations  on  the  Kidney  and  Ureter. — Nephrot- 
oray  means  incision  of  a  kidney,  but  the  term  is  sometimes, 
though  wrongly  applied,  to  the  exploratory  exposure  of  the 
kidney  without  incision.  The  instniuicnts  required  are  scal- 
pels, a  blunt-pointed  bistoury,  dissecting-forceps,  toothed  for- 
ceps, a  grooved  director,  hemostatic  forceps,  spatulae,  metal 
retractors,  a  fountain  syringe,  an  Allis  dissector,  Hagedorn 
needles,  and  an  Abbe  needle-holder.  If  looking  for  a  stone, 
have  a  large  harelip-pin  to  sound  with,  forceps  and  a  scoop 
to  remove  the  stone,  and  a  periosteum-elevator  to  scrape 
away  adherent  calculi.  The  patient  lies  upon  the  sound  side, 
a  sand-pillow  being  placed  under  the  loin.     The  incision  is 


960  DISEASES   OF  GENITO-URIXARY  ORGANS. 

made  half  an  inch  below  the  last  rib  and  close  to  the  outer 
border  of  the  erector  spina;  mass,  and  runs  obliquely  down- 
ward and  forward  toward  the  iliac  crest  for  three  inches,  the 
incision  being  enlarged  later  if  required.  Divide  the  skin,  the 
superficial  fascia,  the  fat,  the  external  oblique,  the  posterior 
border  of  the  internal  oblique,  and  the  outer  edge  of  the  latis- 
simus  dorsi.  This  incision  exposes  the  lumbar  fascia.  Push 
aside  the  last  dorsal  ner\'e  and  incise  the  lumbar  fascia,  when 
the  perirenal  fat  will  bulge  into  the  wound.  Two  distinct 
layers  of  fat  exist.  Tear  this  fat  through  with  dissecting- 
forceps  or  with  an  Allis  dissector  to  expose  the  kidney, 
which  can  now  be  opened  while  it  is  forced  into  the  wound 
by  the  hand  of  an  assistant  making  abdominal  pressure. 

Kocher's  incision  for  nephrotomy  is  begun  in  the  angle 
between  the  sacrolumbalis  muscle  and  the  twelfth  ribband  is 
carried  downward,  forward,  and  outward  to  the  axillar)'  line. 
This  incision  divides  the  skin,  subcutaneous  tissues,  lumbar 
fascia,  the  latissimus  dorsi,  and  the  serratus  posticus  inferior 
muscles. 

Edebohls's  method  enables  the  surgeon  to  most  thor- 
oughly explore  the  kidney,  because  this  organ  is  brought 
outside  of  the  body.  The  patient  lies  prone,  with  a  large 
cylindrical  inflated  rubber  pad  beneath  his  abdomen.  A  ver- 
tical incision  is  made  close  to  the  border  of  the  erector  spinae 
muscle,  from  just  below  the  last  rib  to  just  above  the  iliac 
crest.  The  fatty  capsule  is  well  separated  from  the  kidney  front 
and  back.  The  patient  is  pulled  by  the  legs  toward  the  foot 
of  the  table,  the  pad  remaining  stationar}\  This  change  of 
po.sition  brings  the  pad  beneath  the  chest,  abdominal  respi- 
ration takes  place,  the  kidney  is  forced  out  of  the  wound, 
and  can  be  thoroughly  examined. 

Nephrolithotomy. — In  this  operation  the  incision  is  the 
same  as  in  nephrotomy.  If  the  kidney  is  not  much  enlarged, 
it  can  be  brought  out  by  Edebohls's  method.  Feel  the  kid- 
ney for  a  stone,  or,  if  this  procedure  fails,  explore  with  a  needle 
or  a  pin.  If  no  stone  is  found,  open  the  pelvis,  let  an  assist- 
ant grasp  the  pedicle  with  his  fingers  or  with  a  pair  of  forceps, 
each  blade  of  which  is  covered  with  a  bit  of  rubber  tube,  while 
the  surgeon  opens  into  and  explores  with  the  finger.  If  a 
stone  is  detected,  open  the  kidney-tissue,  loosen  the  calculus 
with  the  nail,  and  remove  it  with  the  finger,  with  a  scoop,  or 
with  forceps.  After  removing  the  stone  suture  the  incision 
with  catgut,  and  release  the  pressure  on  the  pedicle.  Hem- 
orrhage will  rarely  occur.  If  in  spite  of  this  plan  bleeding 
occurs,  take   out  the  stitches  and  apph'  pressure  and  hot 


XEPH RECTO  MY.  96 1 

water,  or  in  some  cases  plug  with  iodoform  gauze  for  twentj'- 
four  hours.  When  hemorrhage  ceases  put  a  large  drainage- 
tube  down  to  the  kidney.  Close  the  wound  in  the  muscles 
and  integument  and  dress  antiseptically.  The  dressings  must 
be  changed  frequently  and  the  tube  should  be  shortened 
daily. 

Nephi'ectomy  is  the  remo\"aI  of  a  kidney.  There  are  two 
methods  oi  nephrectomy,  the  lumbar  and  the  abdoviinal.  Be- 
fore perlbrming  nephrectom\-  ascertain  the  competence  of  the 
kidneys.  If  at  least  i  £er  cent,  of  urea  is  not  being  excreted, 
it  is  ver}'  unsafe  to  operate.  Be  sure  the  patient  possesses  two 
kidneys.  Examination  of  the  bladder  by  a  cystoscope  will 
show  the  ureteral  orifices,  a  strong  indication  that  both  kid- 
neys are  present.  Nevertheless,  when  we  reflect  that  a 
horseshoe  kidney  has  two  ureters  the  proof  is  not  absolute. 
Catheterization  of  the  ureters  is  advisable  if  it  can  be  per- 
formed, but  it  will  probably  require  a  specialist  to  perform 
it.  Proof  absolute  QiLllie_pi::es;ence  of  two  kidneys  consists 
inJ^elingrbbtlTof  .them.  If  in  doubt  as  to  the  question,  and 
if  uncertain  as  to  the  competence  of  the  organ  which  is  to 
be  left,  feel  each  kidney  during  the  operation  and  before 
removing  either,  or  perform  a  preliminar}-  explorator}- 
laparotomy. 

Lumbar  Nephrectomy. — The  instruments  required  for 
this  operation  are  scalpels,  a  blunt-pointed  bistour}-,  forceps 
as  used  in  the  preceding  operation,  a  clamp,  retractors, 
spatulae,  blunt  hooks,  an  aneur}-sm-needle,  a  pedicle-needle, 
a  grooved  director,  stout  silk,  an  Allis  dissector,  sharp 
spoons,  and  a  Paquelin  cauteiy.  The  patient  is  placed  on 
the  sound  side  and  a  pillow  is  placed  under  the  loin.  Sev- 
eral incisions  ha\"e  been  proposed.  In  many  cases  the  / 
oblique  incisj^  is  first  made  to  permit  of  exploration.  This 
incision  is  begun  half  an  inch  below  the  last  rib  and  by  the 
edge  of  the  erectqr^pinae  muscle,  and  is  carried  downward 
and  forward  toward  the  iliac  crest.  In  some  cases  a  kidney 
can  be  removed  through  this  cut.  In  other  cases  the  cut 
must  be  enlarged.  It  can  be  enlarged  by  extending  the  cut 
downward.  ]\Iorris  enlarges  it  b}*  adding  to  it  a  vertical  -, 
incision,  which  begins  one  inch  below  the  origin  of  the 
oblique  cut.  Konigls-  incision  for  nephrectomy  consists  of 
a  vertical  cut  by  the  edge  of  the  erector  spinae,  carried  almost 
to  the  iliac  crest,  from  which  point  it  is  cur\'ed  forward 
toward  the  umbilicus,  and  is  carried  to  or  even  through 
the  rectus  muscle.  After  thorough  exposure  lift  the  kidney, 
and  separate  it  from  the  peritoneum,  if  possible,  with  the 

61 


962  DISEASES   OF  GENITO-URINARY  ORGANS. 

finger;  clamp  the  pedicle;  pass  an  armed  aneurysm-needle 
between  the  vessels  of  the  pedicle;  ligate  in  two  places;  cut 
between  the  threads ;  and  arrest  hemorrhage  by  ligature  or 
by  the  cauteiy.  If  the  ureter  be  healthy,  ligate  it  with  silk 
and  drop  it  back ;  if  it  be  foul  and  purulent,  scrape  it  with 
a  spoon,  wash  it  with  corrosive  sublimate,  and  touch  it  with 
pure  carbolic  acid,  and  then  either  ligate  it  and  drop  it  back 
or  sew  it  into  the  wound.  If  hemorrhage  persists  from  the 
wound,  plug  with  gauze.  Put  in  a  drainage-tube  and  close 
the  wound.  If  the  peritoneum  be  accidentally  opened,  close 
it  with  Lembert's  suture.  Kocher's  method  is  excellent, 
and  enables  the  surgeon  to  feel  the  opposite  kidney  before 
removing  the  one  which  is  known  to  be  diseased.  The 
incision  is  begun  as  described  on  page  961,  and  is  car- 
ried forward  so  as  to  expose  the  reflection  of  the  perito- 
neum onto  the  colon  in  the  posterior  axillary  line.^  At  this 
point  the  peritoneum  is  opened,  and  the  hand  is  inserted 
into  the  abdominal  cavity  and  feels  the  other  kidney.  If 
another  kidney  exists  and  it  is  found  to  be  healthy,  the 
diseased  organ  is  removed. 

Abdominal  nephrectomy  is  more  dangerous  than  the 
lumbar  operation.  The  same  instruments  are  required  as 
are  used  in  the  preceding  operation.  The  position  is  supine. 
The  incision  is  that  of  Langenbeck — four  inclies_loiio;^irL_the 
linea  semilunaris,  its  center  corresponding  to  the  umbilicus. 
Open  the  abdomen,  introduce  a  hand,  feel  the  kidneys,  and 
if  both  show  serious  disease  do  not  perform  nephrectomy. 
Keep  the  small  intestine  away  by  sponges,  push  the  colon 
toward  the  umbilicus,  incise  the  outer  layer  of  the  meso- 
colon, and  bare  the  kidney.  Strip  off  the  peritoneum  from 
the  kidney  and  its  vessels,  and  ligate  the  vessels  by  pass- 
ing strong  silk  through  the  center  of  the  pedicle  with  an 
aneurysm-needle.  Ligate  the  ureter  if  healthy,  and  cut.  If 
the  ureter  is  septic,  fasten  it  to  an  opening  made  in  the  loin 
by  cutting  onto  forceps  pushed  to  the  outer  edge  of  the 
quadratus  lumborum.  Stop  bleeding,  irrigate  the  belly- 
cavity,  and  dress  as  usual,  employing  drainage  only  when 
septic  matter  has  gotten  into  the  peritoneal  cavity  or  when 
oozing  is  persistent. 

Partial  Nephrectomy. — This  operation  may  be  performed 
in  some  cases  for  wounds,  cysts,  and  innocent  tumors.  After 
removing  the  damaged  or  diseased  part  bleeding  points  are 
ligated  with  catgut.  The  wound-surfaces  are  approximated 
as  well   as   possible  by  catgut  sutures.     Drainage  is  intro- 

^  Kocher"s  Text-book  of  Operative  Surgery. 


r. 


OPERATIOXS   OX   THE  KIDXEY  AXD    URETER.      963 

duced.  The  value  of  partial  nephrectomy  in  some  cases 
seems  certain,  and  we  should  apph*  it  when  possible  instead 
of  the  complete  operation.^ 

Renipuncture. — This  is  an  operation  devised  by  Reginald 
Harrison  for  the  relief  of  albuminuria  due  to  elevated  ten- 
sion. The  kidney  is  exposed  in  the  loin  and  the  capsule  is 
punctured  or  incised.  Simple  incision  of  the  capsule  will 
usually  relieve  nephralgia. 

Nephrorrhaphy  (or  nephropexy)  is  fixation  of  a  mobile 
kidney.  The  kidney  is  exposed  in  the  loin  as  above  detailed, 
and  is  forced  out  of  the  wound  by  Edebohls's  method.  The 
fibrous  capsule  is  incised  longitudinally  and  a  cuff  is  turned 
down  on  each  side.  Sutures  traverse  the  kidney-substance 
and  two  layers  of  capsule  on  each  side.  The  upper  suture 
catches  the  periosteum  of  the  last  rib,  the  lower  sutures 
catch  the  lumbar  fascia.  Drainage  is  not  required.  The 
suture-material  is  kangaroo-tendon  or  chromicized  catgut. 
Kocher's  incision  is  shown  in  Fig.  107.  ]\Iany  surgeons 
simply  pass  sutures  through  the  uncut  capsule  and  kidne}-- 
substance,  and  fasten  the  kidney  to  the  lumbar  fascia.  Other 
surgeons  split  the  capsule,  pull  it  into  the  wound,  and  pass 
sutures  through  only  the  capsule  and  wound-edges.  After 
nephrorrhaphy  keep  the  patient  in  bed  for  three  weeks.  A 
kidney  which  has  been  anchored  will  not  unusually  loosen 
at  some  future  time. 

Senn's  Operation. — Man}-  surgeons  feel  that  it  is  not  de- 
sirable to  pass  sutures  through  the  kidney-substance. 
Urinary  fistula  has  followed  suturing.  Again,  the  value  of 
such  sutures  is  very  doubtful.  The  kidney  is  a  very  soft 
organ,  and  if  it  is  suspended  by  sutures  they  are  certain  to 
cut  out.  Senn's  operation  fixes  the  kidne}-  without  using 
sutures. 

The  kidney  is  held  in  place  b}'  an  assistant.  A  vertical 
lumbar  incision  is  made,  the  perirenal  fat  is  exposed  and 
is  torn  through  until  the  kidney  is  reached.  The  kidne}-  is 
usually  brought  out  of  the  w-ound.  The  posterior  fattv 
capsule  is  cut  awa}-,  and  also  the  anterior  capsule  up  to  the 
hilum.  The  true  capsule  of  the  kidne}-  is  scarified,  a  long 
piece  of  iodoform  gauze  is  placed  under  the  upper  end  of 
the  kidney,  and  another  piece  under  the  lower  end.  The 
kidney  is  replaced  and  will  then  lie  in  a  sling,  composed  of 
two  pieces  of  gauze,  the  ends  of  Avhich  protrude  from  the 
wound.     Gauze  is  packed  into  the  opening  over  and  about 

^  See  Oscar  Bloch,  in  British  Med.  Jour.,  Oct.  17,  1S96;  also,  reports  of 
Czemy,  Bardenheuer,  Tuffier,  and  Kiimmell. 


964  DISEASES   OF  GEXITO-URINARY  ORGANS. 

the  kidney,  and  over  this  the  two  long  pieces  are  tied.  A 
large  gauze  pad  is  placed  upon  the  abdomen  over  the  anterior 
surface  of  the  kidney,  and  the  lumbar  wound  is  dressed 
with  gauze.  The  dressing  and  gauze  pad  are  held  in  place 
by  a  binder.  In  about  ten  days  the  patient  is  anesthetized, 
the  gauze  is  removed,  and  the  granulating  surface  is  lightly 
packed  with  gauze.^  By  this  operation  the  kidney  is  sur- 
rounded with  granulations,  which  are  converted  into  scar- 
tissue,  and  the  organ  becomes  encased  in  a  box  of  fibrous 
tissue. 

Ureterolithotomy. — If  the  stone  is  impacted  in  the  upper 
two-thirds  of  the  tube,  make  the  incision  advised  for  wounds 
of  the  ureter  (p.  952).  The  operation  is  extraperitoneal. 
The  tube  is  opened  by  a  longitudinal  incision.  The  stone  is 
remo\ed.  The  ureter  is  explored  by  means  of  a  sound.  It 
is  not  necessaiy  to  suture  the  ureter.  The  tissues  above  the 
ureter  are  sutured  and  a  drainage-tube  is  carried  to  the 
duct  (Fenger).  If  the  stone  cannot  be  reached  by  the 
extraperitoneal  method,  open  the  peritoneal  cavity  and  incise 
the  ureter.  After  removing  the  stone  suture  the  wound  in 
the  ureter  with  silk  inversion-sutures,  fasten  an  omental  graft 
over  the  suture-line  (Fengerj,  and  drain. 

Uretero-ureterostomy  (Van  Hook's  Operation). — In  this 
operation  ligate  the  lower  end  of  the  divided  ureter  with 
silk  or  catgut.  About  one-fourth  of  an  inch  below  the  liga- 
ture make  an  incision  in  the  long  axis  of  the  tube.  This 
incision  is  in  length  equal  to  twice  the  diameter  of  the  tube. 
Each  end  of  a  piece  of  fine  catgut  is  threaded  to  a  fine 
needle.  This  thread  is  passed  through  the  upper  end  of 
the  ureter  (Fig.  378).  The  needles  are  made  to  enter  the 
low^er  end  of  the  tube  through  the  door  made  by  the  sur- 
geon. They  are  pushed  through  the  wall  of  the  ureter  one- 
half  an  inch  below  the  window  (Fig.  378).  Traction  upon 
the  strings  causes  invagination  and  the  ligature-ends  are  tied. 
If  the  operation  is  intraperitoneal,  the  ureter  is  wrapped 
about  with  peritoneum. 

Intestinal  Implantation  of  the  Ureters. — This  operation 
may  be  employed  in  exstrophy  of  the  bladder  and  in  vesical 
cancer,  in  which  it  is  necessary  to  remove  the  bladder. 
After  this  operation  there  is  danger  of  infection  of  the  ureters 
and  consequent  ascending  ureteritis,  and  pyelonephritis. 
After  the  operation  the  presence  of  urine  in  the  bowel 
usually  causes  inflammation  of  the  rectum,  and  incontinence 
of  urine  may  take  place. 

^  See  John  B.  Deaver,  on  "  Movable  Kidney,"  Annals  of  Surgery,  June,  1899. 


RETEXTIOX  OF  URIXE. 


96; 


]\Ia}"dl  asserts  that  a  piece  of  the  bas  fond  should  be  re- 
moved with  the  ureter,  and  implanted  with  it  into  the  intes- 
tine, the  flange  hanging  free  in  the  lumen  of  the  gut.  If  this 
is  done,  the  relations  of  the  ureter  to  the  muscular  coat  of  the 
bladder  are  not  interfered  with,   stricture  is  less  likeh-  to 


Fig.  37S. — Van  Hook's  method  of  ureteral  anastomosis. 


occur,  ascending  infection  is  antagonized,  and  suppurative 
conditions  arise  at  the  margin  of  the  flange,  rather  than  as 
in  other  methods,  directly  in  the  cut  ureter.  ]Maydl  has 
collected  the  records  of  fourteen  cases  operated  upon  b}- 
this  method,  with  two  deaths.^ 


Diseases  and  In'juries  of  the  Bladder. 

Retention  of  Urine. — By  this  term  is  meant  an  inabilit}- 
to  empt}-  the  bladder.  The  retention  mav  be  complete,  v^ot 
a  drop  emerging,  or  it  may  have  been  complete,  a  dribbling 
seTting  in  after  a  time,  due  to  paralysis  of  the  bladder,  which 
cannot  contain  more  fluid,  expulsion  of  the  overflow  from  the 
ureters  being  produced  by  atmospheric  pressure.  This  con- 
dition is  known  as  thc_cngorgciiic]it.  the  ovcrjloic,  or  the  iii- 
coiitiTicnce  of  reteiition.  There  ma\'  be  a_/rt^;::^/<iZ_xeteution 
from  enFarge^  prostate,  a  portion  only  of  the  urine  being 
voided.  Retention  may  be  caused  by — ( i )  obstriiction .  result- 
ing  from  urethral  stricture,  hypertrop hied  prostate,  inflamed 

1  Editorial  m  Join:  Amer.  Med.  Assoc,  May  6,  1899. 


966  DISEASES   OF  GENITO-URINARY  ORGANS. 

prostate,  occluded^meatus,  impacted  cajculus,  urethral  tumor, 
completephimosis,  Fecalimp^llon,  and  pressufe  from  a  Targe 

"  '  tamorToTDyl^S)  defective  expulsion,  resulting  from  paralysis, 
disease  or  injury,  atony,  reflex  inhjbition,  shock,  muscular 
VveaTcness  of  fevers,  and  the  action  of  su^h   drugs  as  bella- 

"'),  donna,  opium,  or  cantharides. 

Symptoms. — In  acuteTetention  there  is  an  agony  of  desire 
to  urinate,  thejg^atient  rnaking  acutely  painful  straining- efforts, 
during  which  feces  are  often  passed.  There"  are  seyere^ain 
and  aching  in^  the  abdomen,  thighs,  perineum,  and  penis. 
All  the  symptoms  rapidly  increase,  a  typhoid  state  is  inaug- 
urated, and  death  closes  the  scene  unless  relief  be  given. 
If  retention  is  from  time  to  time  alleviated  by  the  passage 
of  a  little  water,  the  symptoms  are  slower  in  evolution  and 
are  less  intense,  and  the  case  is  said  to  be  chronic.  Some 
cases  of  gradual  onset,  due  to  atony,  are  very  insidious,  the 
patient  feeling  no  particular  pain  and  complaining  only  of 
the  dribbling,  which  is  really  the  overflow  of  retention,  and 
is  not  a  sign  that  the  bladder  is  successfully  emptying  itself 
In  any  case  of  retention  the  bladder  rises  above  the  pubes, 
and  there  is  found  a_pyriform,  elastic,  fluctuatmg  mass  (dull 
on  percussion)  in  the  h^ypogastriurn,  whicli  m.ass  gradually 
enlarges  until  the  bladder  is  evacuated  or  incontinence  sets 
in.  The  flanks  give  a  clear  percussion-note,  and  the  tumior  is 
more  prominent  when  the  patient  is  erect  than  when  recum- 
bent. Long  fcontinuation  of  obstructive  disease,  producing 
partial  retention  with  or  without  attacks  of  complete  reten- 
tion, disorganizes  the  kidneys.  Acute  and  complete  retention 
may  induce  rupture  of  the  urethra  or  urinary  s-uppression. 

Treatment. — Place  the  patient  upon  his  back,  keep  him 
warm,  and  if  instrumentation  does  not  rapidly  succeed,  give 
an  anesthetic.  Be  sure  that  every  instrument  is  aseptic. 
In  organic  stricture_Xry  to  pass  a  soft  catheter;  if  this 
fails,  endeavor  to  insert  a  hard  catheter.  Try  a  large  size 
first,  and  gradually  go  to  smaller  sizes  if  the  larger  instru- 
ment will  not  pass  the  obstruction.  When  the  instrument 
enters  the  bladder  draw  off._but..haIf  of  Jhe  urine,  withdraw 
the  instrument,  wait  a  few  hours,  insert  it  again  and  then 
empty  the  bladder  and  wash  out  the  viscus  with  hot  boric- 
add  solution.  To  draw_aff_all  of  the  urine  at  once  is  dan- 
gerous, because  the  sudden  rehef  of  pressure  from  distended 
veins  leads  to  bleeding  from  the  mucous  membrane  and 
hemorrhage  into  the  bladder-walls.  Fig.  381  shows  several 
varieties   of   rubber    catheters,  and    Fig.  383    shows   a   silk 


RETENTION  OF   URINE. 


967 


catheter.  Fig.  382  shows  the  proper  curve  and  the  im- 
proper curve  for  a  metal  instrument.  After  the  bladder  has 
been  emptied  the  patient  is  wrapped  in  blankets,  a  bag  of 
hot  saiid  is  placed  against  the  perineum,  and  a  hot-water  bag 
over  the  hypogastric  region ;  when  he  recovers  from  the 
effect  of  the  anaesthetic  he  is  given  suppositories  of  opium 
and   belladonna,  and   tablets    of    salol  and  boric  acid  are 


jr[Q_  379._Gouley.'s  tunnelled  catheter  threaded  on  a  filiform  bougie. 


/     I 


administered  for  several  days.     If  jt  is  found  impossible  to 
insert  a  rubber  instrument  or   a  ^metal    catheter,  make    an 
attempt  to  carrv  a  filiform  bougie  into  the  bladder.     Fig.  380 
shows   filiform 'bougres.      If   the   stricture   is   known   to  be 
organic    from    previous    history,    at    once    insert    a    filiform 
bougie.     On  this  bougie  Gouley's  tunnelled  catheter  can  be 
threaded  (Fig.  379)  and  carried  into  the  bladder,  the  viscus 
being  half  emptied.    Instead  of  carrying  in  the 
catheter,  we  can  leave  the  filiform  in  place, 
and  fasten  it.     The  filiform  bougie  will  act 
as    a    capillar}'   drain,  and    in    a   few    hours 
wrir empty  the  Jbladder.      Then   insert   an- 
other  bougi£_bes,ide    the   first,    and   so    on 
for    several    days,  using    also    opium,  order- 
ing rest  in  bed,  arid  making  no  attempt  to 
dilate  ~the   stricture    forcibly  until   retention 
has  ceased  and  inflammation   has   subsided. 
If  nobougie  can  be  passed,  asph'ate  or^erform  cystotomy  (su- 
prapubic or  perineal).  In  spasmodic  stricUirc  hold  a  good-sized 
metal  catheter  firmly  against"  the  face  of  the  spasmed  area ; 
relaxation  will  occur  and  the  instrument  will  eventually  pass. 
An  individual  who  has  an  organic  stricture  which  has  given 
but  little  trouble  may  develop  attacks  of  retention  because 
of  inflammatory  edema  of  the  mucous  membrane  and  spasm 
of  the  urethral  muscles.    These  attacks  are  temporary,  and  an 
instrument  can  usually  be  inserted  when  employed  as  above 
directed.     In   inflammation  give   a   hot    hip-bath   and  sup- 


Fig.  380. — Points  of 
Gouley's  whalebone 
suides. 


968 


DISEASES   OF  GENITO-URINARY  ORGANS. 


positories  of  opium_  and^  belladonna,  and  then  use  a  hot 
sand-bag  to  the  perineum  and  a  hot-water  bag  over  the 
hypogastrium.  If  these  fail  or  if  the  symptoms  are  urgent, 
pass  a  soft  catheter.  In  the  occluded  meatus  of  the  nezv- 
<^6'77/iiicise_  with^aJienotoiTie.  In  a  congenital  cyst  of  the 
stmts  pocularis_  pass  a  steelbougie.  "which  wilFl-upture 
the~  cyst.  In  cgmpl£te_pJwnosj^_^?>^\^^\\^  the  prepuce.  In 
impacted  stoiie  try  to  pull  it  out  with  urethral  forceps;  if  this 
fails,  cut  the  urethra,  or,  in  rare  cases,  push  it  back  into  the 
bladder.  In  fecal  impaction  sci-ape^Qut  the  rectum  with  a 
spoon.  In  enlarged  prostate  insert  a  coude  catheter  (Fig. 
381,  b)  strengthened  by  .the  insertion  of  a  filiform  bougie 
nearly  to  the  beak,  or  pass  a  silver  instrument  with  a  large 
curve.  In  retoition  from  expidsive  defect  use  a  soft  catheter. 
Cases  of  retention  require  warmth,  confinement  to  bed,  the 


.Fig.  381. — a,  French  olivary  gum  catheter;  /',  Mercier's  elbowed  catheter  (coude);  c,  Mer- 
cier's  double-elbowed  catheter  ;   d,  curved  gum  catheter. 


administration  of  laxatives,  free  action  of  the  skia^and  the  use 
of  such  drugs  as  salol,  boric  acid,  urotropin,  and  quinin  to 
asepticize  the  urine.  In  some  few  cases  no  instrument_can 
be  inserted  in  the  bladder.  In  most  of  such  cases  aspirate — 
which  may  be  done  several  times  if  necessary — and  in  a  day 
or  two,  when  swelling  and  congestion  abate,  an  instrument 
can  be  passed.  A  small  asepticized  trocar  or  aspirator- 
needle  is  pushed  into  the  bladder,  the  trocar  or  needle  being 
inserted  in  the  median  line,  just  above  the  pubes,  and  taking 
a  course  downward  and  backward.  The  parts  are  first  pre- 
pared antiseptically,  and  the  puncture  is  dressed  with  iodo- 
form and  collodion.  Only  half  of  the  urine  is  withdrawn  at  a 
first  aspiration.  Rectal  puncture  is  now  obsolete.  The  peri- 
neal incision  is  not  advocated  for  retention  unless  rupture  of 
the  urethra  has  taken  place.  When  a  catheter  is  used  for 
retention  the  patient  must  be  recumbent  to  minimize  sho.ck. 


DISE.-ISES  AXD  /XJi'R/ES   OF  THE  BLADDER.       969 

Congenital  Defects  of  the  Bladder. — Exstrophy  of 

the  Bladder  (iiV/./.j^Jlij-^iV- — ExsirLiph}"  of  the  bladder  jis_a 
c  o  ndition  of  defecd\  e  dexelogment  commonerjnrnales  than 
intemales.  The  anterior  abdominal  ^all  fia\"ing~failed  to 
"cTose.  the~anterior  wall  of  the  bladder  being  absent,  and  the 
arch  oi  the  pubes  not  having  developed,  epispadias  exists, 
and  in  man}'  cases  the  testicles  do  not  descend  into  the 
scrotum.  In  this  condition  the  posterior  wall  of  the  bladder 
projects  into  or  be\'ond  the  gap  in  the  abdominal  walls; 
the  urine  constantly  flows  and  renders  the  condition  of  the 
patient  dreadful. 

The  onh-  treatment  which  offers  hope  is  operation,  and 
operation  often  fails.  If  possible,  operate  when  the  patient 
is  about  five  years  of  age.  \'arious  operations  have  been 
suggested  for  this  condition,  \\z. :  covering  with  skin  flaps  : 
implanting  the  ureters  into  the  rectum  (Maydl,  Albert,  Roux, 
Simon,  and  others);  di\dsion  of  the  postejipr  ligaments  of 
the  sacro-iliac  joints,  bringing  the  arch  of  the  pubes  forcibly 
together,JtJie  patient  wearing  a  support  until  the  parts  become 
firm,  when  the  defect  is  closed  in  by  flaps  (Trendelenburg) ; 
or^oosening . the jureters  from  the_  bladder,  drawing __them 
down,  and  attaching  them  to  the  end  of  the  penis  (Sonnen- 
berg\ 

iSiseases  and  Injuries  of  the  Bladder. — This  ^-iscus 
is  so  deeply  situated,  and  the  abdominal  walls  are  so  elastic, 
that  it  is  rarely  injured  when  empt}-.  If  the  bladder  be  full 
and  the  abdomen  be  tense — which  is  common  in  alcoholic 
intoxication — force  applied  upon  the  abdomen  may  injure 
the  bladder. 

Contusion  of  the  Bladder. — In  this  condition  there  are 
noted  vesical_  hematuria,  tenesmus^  severe  cystitis,  and  an 
impediment  to  the  flow  of  water  ^because  of  clots.  Hemor- 
rhage may  be  ver\^  severe  and  sepsis  may  arise,  even  causing 
death.  When  contusion  exists  retention  is  relieved  by  means 
of  a  clean, soft:  catheter ;  if_this_fails  because  of  occlusion  of 
the  eye  of  the  catheter  ^\-ith  blood-clot,  there  must,  from 
time  to  time,  be  passed  through^the  catheter  from  a  fountain- 
syringe  a  solution  of  sodium  bicarbonate  in  cooled  boiled 
water.  Gross's  blood-catheter  can  be  used,  or  the  evacuator 
of  Bigelow  may  be  employed.  The  patient  is  put  to  bed, 
a  hot-water  bag  is  applied  to  the  hypogastrium,  morphin 
is  administered  in  moderate  doses,  the  bladder  is  washed 
out  several  times  a  day  with  boric-acid  solution  to  dis- 
integrate and  remove  blood-clots,  and  the  urine  is  diluted 
and  rendered  aseptic  by  the  stomach  administration  of  salol. 


970 


DISEASES    OF   GENITO-URINARY  ORGANS. 


boric  acid,  and  the  free  use  of  bland  fluids.  Hemorrhage 
usually  ceases  on  relieving  distention;  if  it  does  not,  some 
more  radical  measure  must  be  employed  (see  Hematuria). 

Besides  being  contused,  the  bladder  may  be  injured  by  bul- 
lets; by  stabs  or  punctures  through  the  abdomen,  the  yagiiia^ 
or  the  uterus;  or'by  penetration  by  a  fragment  of  a  fractured 
pelvfc  tone?    The  symptoms   of  such   conditions  are  those 


Fig.  382. — A  B  E  shows  the  proper  curve  (reduced  in  size)  for  unyielding  male  urethral 
instruments  ;   C  B  D  shows  an  improper  curve. 

of  rupture  of  the  bladder  {q.  z/.).  In  any  intraperitoneal 
wound  at__once,x)p>en-the^abdomen,  suture  the  wound  in  the 
bladder-wall,  irrigate  the  peritoneal  cavity,  and  drain  the 
bladder  by  means  of  a  retained  catheter,  a  perineaL  section,  or 
a  suprapubic  cystotomy.  In  an  extraperitoneal  wound  drain 
the  wound  by  a  tube,  and  drain  the  bladder  by  a  retained 
catheter,  a  perineal  section,  or  a  suprapubic  opening. 

Rupture  of  the  bladder  occurs  in  three  forms :  (i)  intra- 
peritoneal— a  rupture  involving  the  peritoneal  coat'^  (2) 
"extTaperitoneal — a  rupture  of  a  portion  of  the  bladder  not 
covered  by  peritoneum;  and  (3)  subperitoneal — a  rupture  of 
the  mucous  and   muscular  coats,  the  urine  diffusing  under 


Fig.  383. — English  silk-web  catheter. 


the  peritoneal  investment.  The  causes  are  of  two  kinds, 
predisposing  and  exciting.  Predisposing  causes  are — disten- 
tion of  bladder ;  drunkenness  ;  ulceration  ;  degeneration  or 
atony  of  the  bladder-coats.  Exciting  causes  are — obstruc- 
tion to  outflow  of  urine  (by  stricture  or  enlarged  prostate) ; 
external  violence  ;  falls  upon  the  feet  and  the  buttocks,  as 
well  as  upon  the   abdomen  ;    lifting ;    straining   at    stool  in 


DISEASES  AXD    IXJCRIES   OF   THE    BLADDER.      97 1 

micturition,  or  during  parturition  ;  and  the  forcing  of  injec- 
tions into  the  bladder.  This  accident  is  commoner  in  men 
than  in  women  (10  to  i),  and  is  rare  in  children. 

Svviptovis^  Diagnosis,  and  Treatment. — The  s\mptoms  are 
not  always  definite,  and  every  characteristic  one  may  be  for 
a  time  absent,  the  patient  seeming  in  some  rare  instances  to 
possess  the  power  of  retaining  his  urine  and  of  voiding  it. 
As  a  rule,  however,  there  are  found  some  or  all  of  the  follow- 
ing symptoms,  following  an  accident  or  occurring  during  the 
progress  of  a  causative  disease  :  collapse  ;  excessive  desire 
to  urinate ;  inability  to  do  so  ;  a  catheter,  when  used,  brings 
awav  pure  blood  or  a  ven,-  little  blood}'  urine  ;  the  catheter 
occasionally  slips  through  the  tear  into  the  cavit}',  and  more 
bloody  water  comes  away:  severe  hypogastric  pain  comes 
on  after. _atemporar}-  sense  of  relief  from  retention ;  shock 
is  so  severe  that  death  may  ensue ;  if  reaction  follows,  there 
is  delirium,  often  septicemia  and  peritonitis;  extensive- infil- 
trations of  urine  maj^  occur.  \\\  intraperitoneal  rnptiire  gen- 
eral_peritonitis  is  certain  to  arise,  but  its  appearance  may 
be  postponed  for  several  da}-s  if  the  urine  is  healthy.  In 
these  cases  the  extravasation  is  noted  as  a  simple  swelling, 
probabh'  on  one  side  onh*.  In  extraperitoneal  rnpttcre  the 
urine  may  infiltrate  the  perineum,  the  scrotum,  the-  thighs, 
and  under  the  integuments  of  the  abdomen  and  the  back, 
and  may  soon  induce  sloughing.  In  subperitoneal  riipture 
peritonitis  is  apt  to  arise.  Injecting  fluid  fails  to  lift  the 
blacJdCT-into  the  hypogastric  region  so  as  to  be  recognizable 
on  percussion.  If  there  is  injected  a  measured  amount  of 
fluid,  less  will  run  out  than  went  in. 

In  doubtful  cases  pump  air  into  the  bladder.  A  bicycle 
pump  can  be  used  (Brown),  or  a  Davidson  syringe  (KeenV 
Keen's  directions  are  to  insert  a  catheter,  empt}'  the  blad- 
der of  urine,  and  connect  to  the  catheter  a  disinfected 
Davidson's  syringe,  a  mass  of  absorbent  cotton  being  fast- 
ened over  the  distal  end  of  the  s}-ringe.  Air  after  it  has 
filtered  through  the  cotton  is  pumped  into  the  bladder :  an 
unruptured  bladder  will  rise  above  the  pubes  as  a  pyriform 
tumor,  t\'mpanitic  on  percussion  ;  a  ruptured  bladder  will  not 
so  rise,  but  the  air  will  pass  into  the  general  peritoneal  cavity. 
In  intraperitoneal  rupture  the  general  peritoneal  cavit}'  will  be 
distended  with  the  air.  In  extraperitoneal  rupture  injection 
will  produce  emphysema  of  the  extravesical  connective  tissues. 
On  removing  the  syringe  the  air  rushes  out  again, if  the 
bladder- is -unruptured^  but  little  if  any  comes  away  if  it  is 
ruptured.     Senn  recommends  injecting  hydrogen  gas  instead 


972  DISEASES   OE  GEXlTO-URLyARY  ORGANS. 

of  air.  The  trcatinciit  of  rupture  of  the  bladder  is  the  same 
as  that  for  wounds  of  the" bladder. 

Atony  of  the  bladder  is  a  condition  in  which  the  expul- 
sive power  of  the  bladder  is  diminished  or  lost  because  of 
impairment  of  muscular  tone.  The  bladder  is  very  thin, 
and  the  muscles  are  flaccid  and  often  the  seat  of  fatty  degen- 
eration. Sometimes  the  viscus  is  very  large  and  sometimes 
it  is  very  small.  A  slight  degree  of  atony  is  physiological 
after  middle  age.  The  causes  are  senility,  distention  from 
true  paralysis,  chronic  overdistention  from  obstruction,  and 
acute  ov^erdistention. 

Symptoms. — In  atony  of  the  bladder  the  patient  passes 
water  frequentl}'  (a  symptom  probably  existing  for  some 
years),  and  especially  at  iiight;  he  may  even  do  so  while 
asleep.  The  stream,  when  voluntarily  passed,  has  no  pro- 
jection, but  drops  at  once  from  the  end  of  the  penis.  Resid- 
ual urine  exists  for  years  and  may  at  any  time  set  up  cystitis, 
and  retention  with  incontinence  is  apt  to  occur.  This  con- 
dition is  noi,  vesical  paralysis  resulting  from  a  lesion  of  the 
nervous  system. 

Treatment. — In  treating  atony  of  the  bladder  measure 
the  residual  urine:  if  it  amounts  to  four  ounces,  use  a  soft 
catheter  night_an,d  morning ;  if  it  amounts  to  six  ounces, 
use  the  catheter  every  eight  hours  ;  if  it  amounts  to  eight 
ounces,  use  the  catheter  every  six  hours  (J.  W.  White). 
The  patient  should  be  taught  how  to  use  the  catheter  and 
how  to  keep  it  sterile.  (For  methods  of  disinfecting  cath- 
eters see  article  on  Hypertrophy  of  the  Prostate  Gland.) 
The  bladder  is  from  time  to  time  washed  out  with  gr.  iij  to 
the  ounce  of  boric-acid  solution  at  a  temperature  of  ioo°  F. 
Strychnin,  electricity,  ergot,  and  urotropin  may  be  ordered. 

Vesical  Calculus,  or  Stone  in  the  Bladder. — The 
salts  normally  in  solution  in  the  urine  may  deposit  as  calculi 
and  may  be  imprisoned  in  any  portion  of  the  urinary  tract. 
The  commonest  cakuli  are  those  composed  of  uric  acid, 
urates,  calcium  oxalate,.aad  fusible  phosphates.  The  forma- 
tion of  uric-acid  and  urate  calculi  is  explained  under  Renal 
Calculus  (p.  952).  Vesical  calculi  are  usually  renal  calculi 
that  have  passed  the  ureter  and  become  enlarged  by  new 
accretions.  Pliosphatic  calculi  ma\'  be  formed  in  the  blad- 
der when  chronic  cystitis  causes  and  maintains  an  alkaline 
urine.  Uric-acid  calculi  are  smooth,  round  or  oval,  and 
hard,  but  easily  broken.  On  section  they  present  the  color 
of  brick-dust  and  are  marked  by  concentric  rings.  Their 
nuclei  are  dark  by  comparison.     They  are  soluble  in  dilute 


VES/CJL    CALCi'LCS,    OR   STO.VE   IX  THE   BLADDER.    973 

potassium  hydrate,  and  with  effervescence  in  nitric  acid. 
They  are  conib_ustible,  and  leave_scarcely  any  ash.  Urate 
of  socIiunri^id~urate^r~amnTonium  often  occur  together  in 
stones,  and  these  calcuh  are  not  in  rings,  are  not  so  hard  as 
the  uric-acid  stones,  and  are  fawn-colored  on  section.  Qxa^ 
late-of-hme  stones  are  round  with  many  projecting  nodes 
hke  the  mulberry,  hence  the  term  "mulberr}^  calculus." 
They  are  ver\-  hard,  and  section  shows  the  color  to  be 
brown  or  green  and  that  they  possess  wavy,  concentric 
rings.  This  form  of  calculus  is  soluble  in  hydrochloric 
acid.  Fusible  calculus,  which  is  composed  of  magnesic 
ammonic  phosphate  with  phosphate  of  lime,  constitutes  the 
commonest  form  of  phosphatic  stone  and  of  large  stone. 
It  is  light,  soft,  smooth,  and  white,,  and  shows  no  laminae  on 
section.  Some  rare  forms  of  stone  are  composed  of  xan- 
thic  oxid,  cystic  oxid,  calcium  phosphate  or  carbonate,  and 
magnesic  ammonic  phosphate  (triple  phosphate). 

A  stone  may  be  formed  having  layers  of  different  sub- 
stances ;  for  instance,  there  is  often  found  a  uric-acid  nucleus 
surrounded  by  phosphates,  the  latter  surrounded  by  some 
uric  acid  or  urates,  and  these  again  by  phosphates.  In  some 
cases  oxalate  of  lime  alternates  with  uric  acid,  urates,  or 
phosphates  (Bowlby).  Bowlby  states  that  the  alternating 
uric-acid  and  phosphatic  layers  are  due  to  the  altering  reac- 
tions of  the  urine;  that  when  the  urine  is  acid  uric  acid  is 
deposited  on  the  stone,  but. when  cystitis  makes  the  urine 
alkaline  the  stone  receives  a  phosphatic  coat. 

Anything  thaFTavors  the  formation  of  an  excessive  uri- 
nary deposit  may  cause  vesical  calculus,  and  among  such 
causes  are  defective  djgestion,  failure  in  processes  of  oxida- 
tion, excess  of  solids  and  nitrogenous  elements  in  the  diet, 
deficient  exercise,  etc.  If  to  the  urinary  condition  estab- 
lished by  the  above  factors  catarrh  of  the  genito-uri- 
nary  tract  is  added,  pus  or  mucopus  in  the  concentrated 
urine  may  induce  stone.  Children  are  predisposed  to  uric- 
acid  stones,  and  old  people  to  phosphatic  stones.  In  an  old 
man  with  enlarged  prostate  and  chronic  cystitis  a  stone  forms 
rapidly  about  any  accidental  nucleus.  The  nucleus  may  be 
phosphate-crystals  glued  together  by  mucus,  a  blood-clot, 
uric-acid  gravel,  or  a  foreign  body.  Stone  is  rare  in  females 
because  of  the  shortness,  the  large  diameter,  and  the  ready 
dilatability  of  the  urethra.  Stone  is  very  rare  in  the  negro. 
Gout,  rheumatism,  lithemia,  enlarged  prostate,  vesical  atony, 
urethral  stricture,  and  catarrhal  inflammation  of  the  kidney, 
the  ureter,  and  the  bladder  are  predisposing  causes. 


974  DISEASES   OF  GENITO-URIKARY  ORGANS. 

Symptoms. — In  not  a  few  cases  the  vesical  symptoms  are 
antedated  by  an  attack  of  nephritic  cohc.  The  severity  of 
the  symptom^_depends  more  on  the  roughness  of  thejjtone 
than  on  its  size.  A  small,  rough  calculu.swill'^  produce 
intolerable  anguish,  whereas  several  large,  smooth  stones 
will  cause  but  nioderate  pain.  A  patient  with  stone  in  the 
bladder  complains  of  frequency  of  micturition,  particularly 
in  the  daytime,  the  desire  being  sudden,  uncontrollable,  and 
invoked  or  aggravated  by  exercise.  This  symptom  is  more 
positive  in  youth  than  in  old  age.  Pain  of  a  sharp,  burning 
character  is  experienced  at__the  end  ^of  micturition,  due  to 
the  contraction  of"  the  empty  bladder  upon  the  stone.  The 
usual  seat  of  this  pain  is  the  under  surface  of  the  head  of 
the  penis,  a  little  behind  the  meatus,  and  the  pain  may  con- 
tinue for  some  time.  By  pulling  on  the  penis  to  relieve  this 
pain  the  prepuce  often  becomes  pendulous.  This  pain 
varies  in  severity,  being  worse  during  cystitis  and  after  exer- 
cise; it  may  be  absent  in  encysted  stone,  it  may  even  almost 
disappear,  and  it  is  always  worse  in  the  young  than  in  the 
old.  Stone  in  chronic  cases  of  atony  and  in  cases  of  vesical 
paralysis  causes  neither  marked  pain  nor  frequency  of  mic- 
turition.^ Attacks  of  cystitis  in  a  man  with  ~carcinus~are 
spoken  of  as  attacks  of  stone.  When  a  stone  is  small  it 
may  during  micturition  roll  into  the  urethral  orifice,  and  so 
cause  a  sudden  interruption  of  the  flow  of  water,  the  stream 
again  starting  when  the  patient  changes  his  position.  This 
symptom  is  rare  in  the  old,  the  stone  in  them  dropping  into 
the  sac  back  of  the  prostate_and  bclozv  the  urethral  orifice. 
Hematuria  may  or  may  not  be  noted;  it  is  most  usual  after 
exercise,  and  occurs  at~the  end  of  the  urinary  act.     Pus  or 

mucapus  will  be  observed  if  cystitis  occurs.    Priapism  occurs 

in  some  ca'ses.  Pain  of  a  reflex  nature  may  be  fel^jnTtlie 
rectum,  in  the  perineum,  or  in  some  distant  part. 

The  above  symptoms,  even  if  all  are  present,  do  not  prove 
that  an  individual  has  a  stone  in  the  bladder.  To_prove_the 
presence  of  a  stone,  it  must  be  touched  with  a  souiid  and 
the  contact  musfbe  felt  and  heard.  To  sound  a  patient,  have 
the  bladder  well  filled  wuth  water,  and  place  him  recumbent 
with  the  knees  drawn  up.  Never  sound  a  person  while  he 
is  standing,  because  of  the  danger  of  syncope.  In  an  ordi- 
nary case  use  a  sound  with  a  very  slight  curve  ;  in  a  man 
with  hypertrophied  prostate  use  a  sound  with  a  short  and 
decided  curve.  The  caliber  of  a  stone-sound  is  No.  1 3  of  the 
French  scale.  The  instrument  is  carefully  boiled  and  anointed 

^  American  Text^book  of  Surgery. 


VESICAL    CALCULUS,    OR   STONE   IN   THE  BLADDER.    975 


with  glycerin.  Examine  the  entire  bladder  systematically, 
and  never  operate  unless  a  stone  be  both  heard  and  felt.  The 
stone  may  be  hard  to  find,  or  it  may  elude  the  instrument 
entirely  when  it  is  encysted,  when  it  rests  in  a  diverticulum, 
when  it  is  fixed  to  the  roof  or  anterior  wall  of  the  viscus,  or 
when  it  is  crusted  with  lymph  or  blood-clot.  In  doubtful 
cases  always  insist  on  a  second  examination,  giving  ether  if 
the  first  was  very  painful.  Occasionally  a  small  stone  will 
be  found  by  using  a  Bigelow  evacuator,  the  current  causing 
tlie  calculus  to.  knock  against  the  tube.  In  many  cases  stone 
in  the  bladder  may  be  detected  by  means  of  tlie  Aj-rays.  A 
stone,  when  it  is  detected,  should  always  be  measured  by  an 
arrangement  like  a  lithotrite.  The  composition  of  the  stone 
is  assumed  from  an  examination  of  fragments  which  pass  by 
the  urethra  or  which  adhere  to  the  measure.  Remember  that 
the  outer  layer  of  a  calculus  may  be  soft  phosphate  and  the 
inner  portion  may  be  the  harder  uric  acid,  urate,  or  oxalate. 
Examine  for  stone  in  females  with  a  straight  sound,  and  in 
cases  of  uncertainty  dilate  the  urethra  and  explore  the  bladder 
with  the  little  finger. 

Treatment. — In  people  predisposed  to  stone  (for  instance, 
by  lithemia)  the  physician  should  forsee  the  danger  and  essay 
to  antagonize  it.  Insist  on  the  urine  being  kept  dilute  by  the 
freest  use-ol  w_ater  and_  of  milk,  and  reduce  to  a  minimum 
tte  amount  of  alcohol,  meat,  sugar,  and  fat  which  is  taken. 
Let  the  patient  live  chiefly  on  green  vegetables,  salads,  bread, 
fruit,  eggs,  fish,  poultry,  weak  tea  or  coffee,  water,  milk,  and, 
if  desired,  a  little  red  wine.  Continued  purging  does  harm  by 
concentrating  the  urine,  though  a  laxative  may  be  employed 
when  indicated.  Moderate  opejvai£_exercise  is  of  immense 
importance,  sunshin^~an3"fi^sh  air  being  Nature's  correctives 
for  a  condition  of  imperfect  oxidation  power.  If  the  urine  be 
very  acid,  use  piperazin,  gr.  xv  to  gr.  xx  daily,  liquor  potassii 
citratis,  phospha!e""o?'sodium,  or  borocitrate  of  magnesium. 
If  the  urine  bephbsphatic,  order  mineral  acids^and.strychnin, 
or  what  seems  to  be  very  efficient,  urotrgpin.  Urotropin  is 
given  in  gr.  v  capsules  four  times  daily.  If  the  urine  be  filled 
with  oxalate,  use  the  mineral  acids  with  an  occasional  course 
of  phosphate  of  sodium.  Travel  and  rest  at  the  seaside  or  at 
some  spa  are  often  of  service  in  all  forms.  Always  endeavor 
to  prevent  cystitis,  and  treat  it  promptly  when  it  does  occur. 
Wken^a  stone  is  once  formed  it  is  an  idle  dream  to  think 
of  dissolving  it.  An  operation  must  be  done.  The  operation 
selected  depends  upon  the  age,  the  state  of  the  bladder  and 
the  prostate,  the  dilatability  of  the  urethra,  the  kidney  con- 


976  DISEASES   OF  GENITO-URINARY  ORGANS. 

dition,  the  size  and  composition  of  the  stone,  and  the  number 
of  calcuh  present  (see  Operations  on  the  Bladder). 

Cystitis. — Inflammation  of  the  bladder  is,  as  a  rule,  a 
complication  of  some  other  disease  of  the  genito-urinary 
tract,  but  it  may  arise  from  cold  and  wet.  Traumatism  from 
a  catheter,  the  presence  of  a  stone,  the  spread  of  a  urethral 
inflammation,  pus  infection,  the  existence  of  tuberculosis  or 
cancer,  and  the  use  of  such  a  drug  as  cantharides,  may  pro- 
duce it.  It  appears  not  unusually  during  an  exanthematous 
fever  or  in  conditions  of  vesical  paralysis ;  it  often  follows 
retention,  frequently  accompanies  enlarged  prostate  and  ure- 
thral  stricture,  and  sometimes  arises  from  concentration  of 
urine  or  accompanies  bladder  growths.  Acute  cystitis  causes 
discoloration  and  swelling  of  the  bladder-walls,  and  there 
is  present  a  catarrhal  discharge  vvhich  is  mixed  with  urinary 
elements,  serum,  mucus,  often  pus  and  epithelial  debris.  Ul- 
ceration, sloughing,  or  false-membrane  formation  may  occur. 
Chronic  cystitis  is  an  inflammatory  condition  always  due  to 
bacteria.  We  frequently  speak  of  a  chronic  cystitis  as  due  to 
stone  in  the  bladder,  hypertrophy  of  the  prostate  gland,  or 
tumor  of  the  bladder.  These  conditions  do  not  cause 
chronic  cystitis,  but  act  by  rendering  the  bladder  vulnerable 
to  micro-organisms.  Among  the  causative  organisms  we 
may  mention  the  bacillus  coli  communis,  the  gonococcus, 
the  bacillus  tuberculosis,  the  bacillus  typhosis,  and  the 
various  pyogenic  bacteria  (Leonard  Freeman).  These 
bacteria  may  gain  entrance  on  instruments ;  or  by  way  of 
the  ureter,  urethra,  the  lymph-vessels,  and  possibly  in  rare 
instances  by  the  blood. 

In  chronic  cystitis  there  is  an  enormous  production  of 
thick,  sticky  mucus  and  the  urine  becomes  alkaline.  The 
excessive  secretion  of  mucus  and  the  great  number  of 
bacteriar~conv'ertThe  urea  into  carbonate  of  ammonium,  and 
this  product,  being  irritant  to  the  bladder-walls,  makes  the 
inflammation  worse.  In  chronic  cystitis  the  bladder  is  con- 
tracted and  has  very  thick  walls,  and  the  mucous  mem- 
brane is  thick,  edematous,  congested,  and  filled  with  large 
veins.  The  bladder  may  be  ulcerated  or  encrusted  with 
urinary  salt.  The  urine  contains  bacteria,  triple  phosphate, 
pus,  blood,  and  mucus,  the  blood  emering  with  the  last  drops 
of  water.     Pyelitis  may  arise  as  a  result  of  chronic  cystitis. 

Symptoms  of  Acute  Cystitis. — Great  frequency  of  mic- 
turition, with  the  passage  at  each  act  of  a  very  small  quan- 
tity of  urine ;  the  desire  to  urinate  is  almost  constantj  a.nd 
there  is  intensely  painful  straining  (tenesmus).     The  pain  is 


CYSTITIS. 


977 


acute  and  scalding,  and  may  be  felt  above  the  pubes  or  in 
the  perineum ;  it  often  runs  into  the  loins  and  the  thighs 
and  radiates  over  the  sacrum.  Pain  above  the  pubes  indi- 
cates involvement  .of  the  fundus,  and  pain  in  the  perineum 
and  in  the  head  of  the  penis  points  to  inflammation  of  the 
bladder-neck.  The  urine,  at  first  clear,  loses  its  transparency, 
becomes  full  of  thick  mucus,  and  often  contains  a  httle  blood 
or  pus.  The  patient  not  unusually  has  some  fever.  A  rectal 
examination  causes  violent  pain.  If  ischuria  takes  place,  there 
will  be  a  chill  and  high  fever,  and  anuria  may  occur  or  vesical 
ruptu.re  may  ensue. 

Treatment. — In  treating  acute  cystitis  endeavor  to  remove 
the  cause.  By  allaying  an  irritation  or  removing  an  obstruc- 
tion the  bladder  will  often  become  able  to  empty  itself  of 
retained  urine,  which  urine  causes  congestion  of  the  bladder 
and  thus  renders  infection  probable  or  may  be  itself  filled 
with  bacteria.  If  g-'-stitis-arises  from  the  administration  of 
cantharidesL4iut_±he.patie_nt  in»bed  and  give  him  liquor  potas- 
sii  citratisr-  If  it  comes  from  the  use  of  a  clean  sound,  order 
rest  in  bed,  suppositories  of  opium  and  belladonna,  diluent 
drinks,  and  the  use  of  ammonii  benzoas  or  of  lupulin.  If 
the  inflammation  is  septic  (as  from  the  use  of  a  dirty  sound), 
or  is  very  acute,  put  the  patient  in  bed,  keep  him  warm,  and 
use  a  hot  sand-bag  to  the  perineum  and  hot  fomentations  or 
poultices  to  the  hypogastrium.  Hot  hip-baths  may  be  used. 
The  hips  had  best  be  elevated  and  the  bowels  be  emptied  by 
salines  and  glycerin  enemata.  An  exclusive  milk-diet  is 
desii-able.^  The  patient  should  drink  copiously  of  sweetened 
water  containing  a  few  drops  of  aromatic  sulphuric  acid  or 
of  milk  of  almonds.  Sterilize  the  urine  by  the  administra- 
tion of  urotropjn,  giving  a  capsule  containing  gr.  7|  of  the 
drug  thiree  times  a  day.  Other  remedies  which  may  be  of 
service  in  sterilizing  the  urine  are  quinin,  boric  acid,  salol, 
brocitrate  of  magnesium,  and  salicylate  of  sodium.  Wash 
the  bladder  out  daily  with  warm  normal  salt  solution  or 
warm^bonc-acid  solutlorL  Thts"cah  be  done  through  a 
soff'catheter  or  better  by  hydrostatic  pressure.  A  valuable 
remedy  consists  of  15  grains  of  salicylate  of  sodium  and  15 
grains  of  benzoic  acid,  given  three  times  a  day  in  a  little 
chloroform  water.  If  the  pain  and  straining  still  continue, 
order — 

B: .   Ext.  sem.  hyoscyamin.,  gr.  viij ; 

Ext.  cannabis  indicae,  gr.  viij ; 

Sacchar.  alba,  gr.  xlviij. M. 

Div.  in  pulv.  No.  .\x. 
Sig.  One  powder  every  three  hours.  (Von  Zeissl.) 

62 


gyS  DISEASES   OF  GENITO-URINARY  ORGANS. 

Or, 

R.  Camphora,  gr.  viij ; 

Ext.  cannabis  indicse,  gr.  viij ; 

Sacchar.  alba,  '  gr.  xlviij. — M. 

Div.  in  pulv.  No.  xx. 
Sig.  One  powder  every  three  hours.  ( Von  Zeissl. ) 

Suppositories  of  extract  of  belladonna  are  of  greaLj^alue. 
Suppositories  each  containing  gr.  j  of  ichthyol  are  of  service ; 
and  one  should  be  used  every  four  hours.  If  these  remedies 
fail,  the  surgeon  will  be  driven  to  order  opium,  which,  unfortu- 
nately, constipates ;  when  it  is  used,  secure  evacuations  by 
the  use  of  glycerin  suppositories,  by  the  administration  of 
saline  cathartics,  or  by  the  employment  of  enemata.  Give 
a  suppository  containing  gr.  j  of  powdered  opium  and  gr.  \ 
of  the  extract  of  belladonna  every  three  or  four  hours. 
Hypodermatic  injections  of  morphin  may  be  required.  If 
retention  occurs,  use  a  soft  catheter.  If  much  blood  is  passed, 
give  internally  the  tinctura  ferri  chloridi  and  blister  the  peri- 
neum. A  very  acute  cystitis  is  rarely  arrested  within  a  week 
or  ten  days. 

Symptoms  of  Chronic  Cystitis. — This  condition  may  be 
a  legacy  from  acute  cystitis  or  it  may  appear  without  any 
acute  precursory  phenomena.  There  will  be  foundJrequency 
of  micturition,  but  not  so  great  as  in  the  acute  form.  There 
will  be  slight  tenesmus,  and  moderate  pain  from  time  to  time, 
running  toward  the  head  of  the  penis.  Constitutional  symip- 
toms  arise  only  when  kidney-damage  has  become  pronounced 
or  sepsis  has  occurred  from  absorption.  The  urine  is  arnm(>_ 
niacal,  fetid^  and  turbid ;  it  is  filled  with  viscid,  tenacious 
niucus  or  with  mucopus;  it  contains  a  great  excess^ of 
phosphates,  and  occasionally  clots  of  blood.  The  condition 
'of  chronic  cystitis  with  the  production  of  immense  quanti- 
ties of  thick  mucus  is  often  called  "  chronic  catarrh  of  the 
bladder."  Chronic  cystitis  may  eventuate  in  the  forma- 
tion of  stone  or  in  the  production  of  serious  diseases  of 
the  bladder,  the  ureters,  and  the  kidneys.  It  often  occa- 
sions retention.  Chronic  cystitis  may  be  due  to  tuberculosis. 
Some  cases  come  on  suddenly,  many  tubercle  bacilli  being 
found  in  the  urine.  In  many  cases  no  tubercle  bacilli  are 
found.  The  tubercular  products  caseate  or  fibrous  organi- 
zation takes  place.  A  cystitis  for,  which^no  cause  can  be 
found,  and  which  is  accompanied  by  pyuria  and~pain,  fs 
possibly  tubercular.  The  cystoscope  in  these  cases  should 
•only  be  used  by  an  expert. 

Treatment. — In  treating  chronic  cystitis  remove  the  cause 


CYSTITIS. 


979 


if  possible  (get  rid  of  a  stone,  evacuate  residual  urine  fre- 
quently, dilate  a  stricture,  and  remove  a  tumor).  For  chronic 
cystitis  certain  remedies  are  taken  by  the  mouth.  Water 
is  drunk  in  large  amounts,  also  iron  spring-water  (Marienbad, 
etc.).  Salol  and  boric  acid,  gr.  v  of  each  fQiir_t[mes_a_day, 
are  very  valuable.  Salol  in  IfuTd  extract  of  triticum  repens 
does  good ;  so  does  chlorate  of  potassium,  gr.  x  daily. 
Either  borocitrate  of  magnesium,  quinin,  or  salicylate  of 
sodium  with  benzoic  acid  may  often  be  used  with  benefit. 
Alum,  tannic  acid,  uva  ursi,  copaiba,  cubebs,  buchu,  and  tur- 
pentine have  all  been  recommended,  and  possibly  may  be  of 
some  benefit.  Urotropin  is  useful  in  cases.  of_chronic^ cyst- 
itis. This  drug  prevents  the  development  of  bacteria  in  the 
mine_^[Nicolaier),  and  antagonizes  the  tendency  to  sepsis  and 
urinary  poisoning.  It  is  given  in  5-grain  capsules,  from  four 
to  six  being  given  daily.  Whatever  remedy  is  used,  see  that 
the  bowels  move  once  a  day,  and  that  the  skin  is  active. 
Champagne  and  beer  must  be  avoided.  If  residual  urine 
gathers,  a  soft  catheter  must  be  regularly  used.  If  it  is 
possible  to  introduce  a  catheter  of  considerable  size,  cathe- 
terization may  be  all  that  is  needed  in  the  case.  In  some 
cases  of  chronic  cystitis  the  retention  of  a  catheter  from 
three  to  five  weeks  is  of  the  greatest  service.  If  the  case 
is  very  severe,  the  bladder  must  be  washed  out  daily 
Avith  peroxTd  of_^hydrogen  (25  to  40  per  cent,  solution), 
nitrate  of^ilver  (i  :  8000),  boric  acid  (5  to  10  per  cent.), 
carbolic  acid  (i  :  500),  corrosive  sublimate  (from  i  :  5000 
to  I  :  20,000),  or  permanganate  of  potassium  ( i  :  4000).  !£_ 
nitrate  of  silver  or  permanganate  of  potassium  is  used,  first 
rmse  out  the  bladder  with  distilled  water.  "If  any  other  agent 
Ts  used,  first  wash  out  the  bladder  with  boiled  water.  The 
daily  injection  of  a  2  per  cent,  solution  of  ichth}^ol  may  prove 
useful.  Some  surgeons  occasionally  employ,  at  intervals  of 
a  number  of  days,  strong  silver  solutions  (30  or  40  grains  to 
the  ounce).  If  a  strong  solution  is  used,  after  the  drug  flows 
away  wash  out  the  bladder  with  a  solution  of  common  salt. 
The  bladder  is  usually  washed  out  by  attaching  to  the  free 
end  of  a  soft  catheter,  the  other  end  of  which  is  in  the  blad- 
der, a  tube  which  is  connected  with  a  graduated  bottle,  the 
force  being  obtained  by  elevating  the  reservoir  (fountain 
irrigation).  The  bladder  can  be  irrigated  without  using  a 
catheter,  the  resistance  of  the  compressor  muscle  of  the 
urethra  being  overcome  by  the  pressure  of  a  column  of 
water.  The  reservoir  is  raised  to  the  height  of  six  feet. 
The  patient  sits  in  a  chair.     The  tube  of  the  reservoir  has 


980  DISEASES   OF  GENITO-URINARY  ORGANS. 

upon  it  a  clamp  to  control  the  flow,  and  in  its  end  a  large 
bulbous  tip  which  will  fill  the  meatus  (Valentine's  instru- 
ment). The  tip  is  inserted  into  the  urethra,  the  clamp  on 
the  tube  is  loosened,  and  the  patient  is  directed  to  take  a 
deep  inspiration.  In  a  -short  time  the  bladder  fills  with  water, 
the  tube  is  removed,  and  the  patient  empties  the  viscus  natu- 
rally. In  some  cases  it  is  necessary  to  wait  quite  a  while 
for  the  column  of  water  to  tire  out  the  muscle.  If  the  fluid 
will  not  enter,  direct  the  patient  to  urinate,  and  then  make 
another  attempt.  After  a  little  practice  a  patient  learns  how 
to  admit  the  fluid. 

In  tubercular  cystitis  Collin  advises  the  instillation  of  30 
minims  of  the  following  mixture  into  the  bladder  and  pos- 
terior urethra:  5  gm.  of  guaiacol,  i  gm.  of  iodoform,  100 
gm.  of  sterile  olive  oil.  About  30  minims  of  this  are  in- 
jected once  a  day.  In  ordinary  non-tubercular  cystitis  he 
uses  a  I  per  cent,  solution  of  guaiacol  carbonate  in  oil.  .If., 
the  ordinary  methods  of  treatment  fail,  if  the  bladder  resents 
catheterization  and  irrigation,  if  in  spite  of  irrigation  the  urine 
does  not  become  clear,  and  if  there  are  evidences  of  infec- 
tion of  the  patient  and  breaking  down  of  his  general  health, 
drain  by  perineal  or  suprapubic  cystotomy  (see  Perineal 
Section,  page  1018)  and  through  the  incision  wash  the  blad- 
der frequently  and  thoroughly.  If  the  persistent  cystitis  is 
due  to  stricture  which  dilatation  fails  to  cure,  perform  exter- 
nal perineal  urethrotomy  and  employ  perineal  drainage. 

Tumors  of  the  Bladder. — Tumors  of  the  bladder  may 
be  either  innocent  or  malignant,  the  latter  being  the  com- 
monest. Innocent  tumors  which  may  arise  from  the  bladder 
are  papillomata  or  villous  tumors,  mucous  polypi,  and  fibrous 
polypi ;  malignant  tumors  are  sarcoma  (rare)  and  carcinoma 
(encephaloid,  rare,  epithelioma,  common). 

Symptoms. — ^^The  innocent  tumors  rarely  cause  cystitis  or 
irritation,  though  by  obstructing  the  ureters  or  the  urethra 
they  may  induce  disease  of  the  kidneys.  Qftenjiemorrhage 
is  the  only  phenomenon  produced  by  a  papilloma  or  a 
mucous  polyp.  Mahgnant  tumors  cause  cystitis,  "and  the 
urine  contains  mucus,  blood,  and  pus.  Innocent  tumors  are 
hard  to  feel  with  the  sound,  but  malignant  tumors  are  easily 
felt.  In  some  cases  a  tumor  can  be  detected  by  a  bimanual 
examination  (a  finger  in  the  rectum  and  the  fingers  of  the 
other  hand  on  the  abdomen).  Make  a  careful  study  to 
determine  whether  or  not  growth  has  infiltrated  the  pros- 
tate, the  seminal  vesicles,  the  rectum,  or  the  perivesical  tis- 
sues.    The  bleeding  in  bladder-growths  is  apt  to  be  profuse. 


OPERATIOXS    OX   THE   BLADDER.  98 1 

and  it  occurs  intermittently.  Bleeding  follows  the  use  of  a 
sound.  The  urine  should  be  examined  microscopically  to 
see  if  it  contains  villi,  portions  of  fibroma,  colonies  of  cancer- 
cells,  or  fragments  of  epithelioma  (White).  A  cystoscope 
should  be  employed  in  order  to  reach  a  diagnosis.  In 
doubtful  cases  exploratory  suprapubic  cystotom\'  is  advis- 
able. 

The  treatment  is  by  suprapubic  c}-stotomy  and  removal 
of  the  growths  The  perineal  operation  only  enables  the 
surgeon  to  reach  and  remove  growths  of  small  size,  pedun- 
culated growths,  and  growths  near  the  neck  of  the  bladder. 
(See  Operations  on  the  Bladder.)  Chismore  has  suggested 
the  removal  of  poh'poid  growths  b}'  means  of  Bigeiow's 
evacuator.  When  the  growth  catches  in  the  eye  of  the 
Instrument  it  is  torn  off  by  slight  traction  and  gentle  rock- 
ing, and  the  suction  which  is  being  made  carries  it  into  the 
reservoir. 

Operations  on  the  Bladder. — Lateral  Lithotomy. — 

Litliotoniy  is the    removal    of    a    stone    from    the    bladder. 

Lateral  litliotomy  is  an  operation  which  is  e\'ery  year  be- 
coming less  popular,  but  which  is  still  employed  by  many 
famous  surgeons,  especially  for  stone  in  children.  This 
operation  should  not  be  performed  if  the  stone  is  over  two 
inches  in  its  short  diameter;  it  is  rarely  justifiable  if  the 
stone  weighs  three  ounces  or  more  (Cage) ;  and  it  must  not 
be  performed  for  enc}'sted  stone,  or  on  a  person  with  a  deep 
perineum,  a  narrow  pelvic  outlet,  or  an  enlarged  prostate. 
For  one  week  before  the  operation  keep  the  patient  in  bed, 
u'ash  out  the  bladder  daily  with  hot  boric-acid  solution,  and 
administer  salol  and  boric  acid  by  the  mouth,  gr.  v  of  each 
four  times  a  day.  The  night  before  the  operation  give  a 
saline,  order  a  hot_bath,and  have  the  perineum,  the  scrotum, 
the  buttocks,  and  the  inner  sides  of  the  thighs  cleansed  and 
dressed  antiseptically.  In  the  morning  an  enema  is  to  be 
given.  At  the  time  of  operation  the  bladder  should  contain 
several  ounces  of  boric-acid  solution.  The  instruments  re- 
quired are  a  lithotomy-knife,  a  straight  probe-pointed  bis- 
toury, a  grooved  staff,  a  stone-sound,  stone-forceps  and 
scoops,  a  tenaculum,  an  aneurysm-needle,  a  fountain-syringe, 
curved  needles  and  a  needle-holder,  hemostatic  forces,  a 
tube  wath  chemise  (Fig.  95),  a  Paquelin  cautery,  a  Clover 
crutch,  and  a  lithotrite. 

Place  the  patient  upon  his  back,  anesthetize  him,  and 
find  the  stone  by  sounding.  If  the  stone  is  not  discovered 
by  the  sound,  do  not  operate.     Place  the  buttocks  so  that 


982  DISEASES   OF  GENITO-URINARY  ORGANS. 

they  project  beyond  the  edge  of  the  table,  introduce  the 
staff  into  the  bladder,  flex  the  legs  and  thighs,  and  fasten 
the  patient  in  the  lithotomy  position  with  a  crutch.  During 
the  first  incision  the  handle  of  the  staff  is  held  toward  the 
1  belly;  after  the  first  cut  the  staff  is  set  perpendicularly  and 
is  hooked  up  under  the  pubes.  An  incision  is  made,  start- 
ing just  to  the  left  of  the  raphe  of  the  permeum  and  ^ne 
and  a  quarter  ihclies  in  froht  of  the  edge  of  the  anus,  and 
passing  downward  and  outward  to  between  the  anus  and  the 
ischial  tuberosity,  but  one-third  nearer  the  former  than  the 
latter.  In  the  adult  this  incision  is  three  inches  long.  The 
first  incision  is  superficial  and  does  not  reach  the  staff,  but 
it  is  this  incision  which  may  cut  the  rectum.  After  making 
the  first  cut^the  nail  of  the  left  index-finger  feels  for  the 
groove  of  tne  staff,  the  staff  is  hooked  up,  the  knife  is 
entered  into  the  groove  and  is  pushed  into  the  bladder,  and 
as  it  is  withdrawn  the  wound  is  enlarged.  As  the  knife 
enters  the  bladder  there  is  a  gush  of  fluid.  The  finger  fol- 
lows the  knife  and  stretches  the  wound,  the  staff  is  with- 
drawn, and  the  stone  is  felt  for  and  extracted  with  forceps. 
Liston  showed  years  ago  the  value  of  keeping  the  finger  in 
the  wound.  This  maneuver  retains  some  water  in  the  blad- 
der, and  as  a  consequence  causes  the  stone  to  rest  at  the 
lowest  part  of  the  viscus,  and  when  the  forceps  are  in- 
troduced they  at  once  come  upon  the  stone.  In  with- 
drawing the  stone  make  traction  in  the  axis  of  the  pelvis, 
and  do  not  rotate  the  calculus  until  it  is  entirely  out  of 
the  prostatic  urethra.  Wash  or  scrape  away  debris  or 
incrustation,  see  that  no  other  stone  is  present,  syringe 
out  the  bladder  with  hot  salt  solution,  insert  a  tube, 
apply  antiseptic  dressings  around  the  tube,  and  put  on 
a  T-bandage.  The  end  of  the  tube  which  is  external  to 
the  dressings  is  fastened  to  the  tails  of  the  T-bandage. 
A  rubber  cloth  is  put  on  the  bed,  under  the  body  and 
legs,  and  the  patient's  buttocks  rest  upon  a  mass  of  old 
linen,  the  scrotum  being  raised  on  a  pad.  The  knees  are 
bent  over  pillows.  Change  the  linen  as  soon  as  it  becomes 
wet.  Remove  the  tube  in  forty-eight  hours.  The  urine 
begins  to  come  by  the  urethra  from  the  eighth  to  the  twelfth 
day.  In  children  the  incision  is  not  so  long,  and  is  dilated 
with  forceps  instead  of  with  the  finger ;  no  tube  is  required. 
In  lateral  lithotomy  the  prostatic  and  membranous  portions 
of  the  urethra  are  opened,  the  prostate  gland  is  partly 
divided  with  the  knife,  and  the  wound  is  dilated  with  the 
finger.    One  objection  to  the  operation  is  that  it  is  possible  to 


OPERATIOXS   ON  THE  BLADDER.  983 

cut  the  rectum,  and  another  is  that  inflammation  ma}-  occlude 
the  ejaculatory  ducts. 

Suprapubic  Lithotomy. — This  operation  is  the  removal 
of  a  stone  through  an  opening  over  the  pubes.  It  is  in  many 
instances  the  preferable  operation.  The  mortalit}-  of  this 
operation  is  higher  in  children  than  that  of  lateral  lithotomy ; 
in  adults  and  in  individuals  beyond  middle  life  the  mortality 
is  decidedly  less  than  is  that  following  the  lateral  operation. 
It  is  used  for  the  removal  of  multiple  calculi,  for  very  hard 
stoiies^Jor- stones  above  one  and  a  half  inches  in  diameter, 
for  calculi  in  men  with  enlargement  of  the  prostate,  for  for- 
eign bodies  incrusted  with  sediment,  when  the  perineum  is 
deep,  when  the  pelvic  outlet  is  narrow,  for  encysted  stones, 
for  calculi  associated  with  a  vesical  tumor  when  the  urethra 
will  not  permit  the  use  of  a  lithotrite.  The  patient  is  pre- 
pared as  for  lateral  lithotomy,  except  that  the  pubes  are 
shaved,  and  the  lower  part  of  the  abdomen  and  the  upper 
part  of  the  thighs  are  disinfected.  During  the  operation  the 
penis  is  wrapped  with  a  piece  of  antiseptic  gauze.  The  in- 
struments required  are  a  scalpel,  a  probe-pointed  bistour}', 
scissors,  a  tenaculum,  blunt  hooks,  hemostatic  forceps,  re- 
tractors, dissecting-forceps,  a  dry  dissector,  an  electric  fore- 
head-light, a  rectal  bag,  a  brass  syringe  or  a  bicycle-pump, 
a  sound,  rubber  tubing,  rubber  catheters,  stone-forceps  and 
scoops,  a  bladder-tube,  curved  needles  and  a  needle-holder, 
and  a  graduated  glass  jar  for  injecting  the  bladder. 

In  performing  the  operation  place  the  patient  in  the  Tren- 
delenburg position.  It  is  necessary  to  distend  the  bladder 
and  raise  it  in  order  to  have  a  prevesical  space  uncovered  by 
peritoneum.  Have  an  assistant  oil  the  rectal  bag  and  push  it 
above  the  sphincters.  Draw  off  the  urine  with  a  soft  catheter, 
wash  out  the  bladder  with  warm  boric-acid  solution  (i  :  32), 
and  inject  the  bladder  with  the  same  solution.  In  a  child 
under  the  age  of  five  inject  three  to  four  ounces;  in  an  adult 
inject  ten  to  twelve  ounces.  Withdraw  the  catheter  and  tie 
a  tube  around  the  penis  to  prevent  the  escape  of  fluid.  After 
injecting  the  bladder  with  fluid,  if  the  viscus  is  not  well  lifted, 
inject  the  rectal  bag  with  water  and  clamp  its  tube  with  for- 
ceps. In  a  child  inject  from  two  to  four  ounces  of  warm  water 
into  the  rectal  bag;  in  an  adult  inject  ten  ounces.  Bristow 
suggested  the  injection  of  air  into  the  bladder.  Some  sur- 
geons simply  inject  air  by  means  of  a  catheter  and  a  brass 
syringe  or  a  Davidson  syringe.  If  air  is  injected,  a  rectal 
bag  is  not  used,  and  the  patient  is  placed  on  his  back  rather 
than  in  the  position  of  Trendelenburg.     The  best  method 


984 


DISEASES   OF  GENirO-URINARY  ORGANS. 


of  injecting  air  is  that  of  F.  Tildcn  Brown,  by  means  of  a 
bicycle-pump.  A  catheter  is  introduced,  the  bladder  is 
washed  out,  the  catheter  is  fastened  to  a  bandage,  the  bicycle- 
pump  is  attached,  the  operation  is  proceeded  with,  and  when 
the  transversalis  fascia  is  exposed  the  bladder  is  filled  with 
air,  the  soft  catheter  is  clamped,  and  the  bladder  is  opened.^ 
Make  a  three-inch  longitudinal  incision  in  the  median  line' 
of  the  hypogastric  region,  terminating  over  the  symphysis. 
When  the  perivesical  connective  tissue  is  reached,  cut  it.  If 
the  peritoneum  should  appear,  push  it  up.    Hold  the  wound- 


FiG.  384. — Keen's  modification  of  Cathcart's  siphonage  apparatus :  A',cavity  to  be  drained; 
A,  reservoir  ;  K,  tube  from  cavity;  B,  tube  from  reservoir  ;  //,  clamp  on  tube  from  reservoir; 
L,  L,  D,  glass  tubes  ;  C,  rubber  tube  connecting  cavity-drain  with  reservoir-drain  ;  E,  S-shaped 
rubber  tube  maintained  in  shape  by  hooking  up  at  F ;   G,  vessel  containing  antiseptic  fluid. 

edges  apart  with  retractors.  The  large  veins  are  seen,  giving 
the  bladder  a  blue  color.  Avoid  these  veins  if  possible,  but 
even  if  they  should  be  cut  bleeding  will  usually  cease  when 
the  bladder  is  opened  and  the  rectal  bag  is  removed.  Clamp 
bleeding  vessels ;  catch  the  bladder  transversely  with  a  tenac- 
ulum at  the  upper  angle  of  the  wound ;  open  the  viscus  in 
the  middle  line  above,  and  cut  toward  the  pubes ;  catch  the 
edges  of  the  bladder  with  hemostatic  forceps,  and  remove  the 
tenaculum.  Explore  the  bladder,  remove  the  stone  or  stones, 
scrape  away  incrustations,  ligate  bleeding  vessels  outside  the 
^  F.  Tilden  Brown,  Annals  of  Surgery,  Feb.,  1897. 


OPERATIONS   ON   THE   BLADDER.  985 

bladder,  and  irrigate  the  viscus  with  hot  saline  solution. 
Introduce  a  tube  into  the  bladder,  and  attach  to  its  external 
end  a  long  tube  to  siphon  off  the  urine.  The  bladder  can 
be  drained  very  satisfactorily  by  tCeen's  siphonage  apparatus 
(Fig.  384).  Suture  the  muscles  and  fascia  at  the  upper  part 
of  the  wound.  Dress  with  dry  antiseptic  gauze  and  a  rub- 
ber-dam, the  dressings  and  binder  being  split  to  go  around 
the  tube.  Catch  the  urine  which  siphons  over  in  a  bottle 
containing  some  antiseptic  fluid.  Change  the  dressings  as 
often  as  they  become  wet.  Take  out  the  tube  in  four  or  five 
days,  and  allow  the  wound  to  heal  by  granulation.  The 
patient  may  get  up  in  two  weeks.  Many  Continental  sur- 
geons advocate  immediate  suture  of  the  bladder  after  incision. 
The  suture-material  should  be  silk  or  catgut.  Albert,  Vincent, 
Bassini,  DeVlaccos,  and  others  advocate  immediate  suture. 
After  suture  a  catheter  is  kept  in  the  bladder  to  drain  the 
viscus.  Immediate  suture  may  be  employed  in  patients  of 
any  age,  but  should  not  be  used  if  the  urine  is  very  septic 
or  if  pyelonephritis  exists.  In  some  cases  the  attempted 
closure  will  fail ;  in  others  it  will  only  partially  succeed ;  in 
many  it  will  prove  successful;  but  even  if  it  only  par- 
tially succeeds  it  will  tend  to  prevent  dissemination  of  urine 
in  the  prevesical  cellular  tissue.  The__chief  causes  of  death 
after  suprapubic  lithotomy  are  septicemia,  secondary  hemor- 
rhage, cellulitis,  peritonitis,  and  suppression  of  urine.  J.  W. 
White  estimates  the  relative  mortality  of  suprapubic  and 
lateral  lithotomy  as  follows  : 

In  children  the  suprapubic  operation  gives  a  mortality  of 
12  per  cent.,  the  perineal  of  3  per  cent.  In  adults  the 
suprapubic  gives  a  mortality  of  12  per  cent.,  the  perineal 
from  8  to  12  per  cent.  In  old  men  the  suprapubic  gives  25 
to  30  per  cent.,  the  perineal  30  to  40  per  cent. 

Crushing-  of  Vesical  Calculi. — This  is  now  done  in  one 
sitting,  the  old  operation  of  Civiale,  which  required  repeated 
crushings,  being  obsolete. 

Litholapaxy  (Bigelow's  operation,  or  rapid  lithotrity)  is 
__the_operation  for  removing  a  stone  in  the  bladder  in  one  sit- 
ting by  thoroughly  crushing  the  stone  and  completely  wash- 
ing away  the  fragments.  This  operation  is  Avonderfully 
successful  if  done  by  an  expert.  Few  of  us  do  it  sufficiently 
often  to  learn  how  to  perform  it  with  great  rapidity,  certaint}^ 
and  safety.  It  is  the  best  operation  in  most  cases,  if  performed 
by  a  very  skilful  man.  It  is  the  operation  in  most  every 
case  for  even  the  general  surgeon  to  select,  but  the  general 
surg-eon   will   have  better  results  in   certain   difficult  cases 


986 


DISEASES   OF  GENITO-URINARY  ORGANS. 


after  suprapubic  lithotomy  than  after  Htholapaxy.  Sir  H. 
Thompson  says  this  method  is  suited  to  twenty-nine  cases 
out  of  thirty.  _Litholapaxy:_  slimjLLd_.  be  employed  if  the 
bladder  will  hold  at  least  six  ounces  of  fluid  and  is  in  a  fairly 
ITealthy  condition;  if  the  urethra  is  tolerant  and  penetrable 
by  instruments ;  if  the  stone  is  not  too  hard,  does  not  weigh 
over  two  and  three-quarters  ounces,  and  is  not  over  two 
inches  in  diameter.  It  is  not  suited  for  multiple  calculi,  for 
large  and  hard  calculi,  for  encysted  stones,  or  for  a  patient 
with  enlarged  prostate,  with  vesical  atony,  or  with  cystitis. 
An    easily    dilatable    stricture    need    not   prevent    the    sur- 


FiG.  385. — Bigelow's  latest  evacuator. 

geon  doing  Htholapaxy.  The  stricture  can  first  be  dilated^ 
and  later  Bigelow's  operation  can  be  performed,  but  firm, 
gristly  strictures  demand  a  cutting  operation.  If  the  ure- 
thra is  intolerant  of  instrumentation,  the  patient  being  prone 
to  febrile  attacks  when  it  is  attempted,  cut  instead  of  crush- 
ing. An  individual  laboring  under  kidney  disease  will  do 
better  after  this  operation  than  after  cutting  (Cage).  In 
diabetes,  locomotor  ataxia,  and  conditions  of  exhaustion 
patients  are  best  treated  by  Bigelow's  operation,  unless 
cystitis  exists. 

The  Indian  surgeons  have  had  the  most  admirable  results 


OPERA  TIOXS   OX   THE  BLADDER. 


987 


from  litholapaxy.  It  has  often  been  claimed  that  such 
results  were  due  to  racial  peculiarities  ot  the 
patients  and  various  factors  regarding  their 
habits,  diet,  etc.  The  fact,  however,  that 
some  of  these  very  surgeons  have  returned 
to  England  and  repeated  their  successes  in 
London,  shows  how  large  a  part  dextent}^ 
played  in  obtaining  success. 

J.  A.  Cunningham^  reports  upon  10,073 
Indian  cases  of  litholapaxy.  The  mortality 
was  3.96  per  cent. 


Fig.  386. — Bigelow's 
lithotrite. 


Fig.  387. — Thompson's 
lithotrite. 


Fig.   38S. — Forbes's 
lithotrite. 


Cabot  of  Boston  in  116  cases  had  but  four  deaths,  and  two 
of  these  were  due  to  pneumonia. 

1  Brit.  Med.  Jour.,  August  7,  1887. 


988 


DISEASES   OF  GENITO-URINARY  ORGANS. 


The  preparation  of  the  bladder  is  the  same  as  for  hth- 
otomy.  Be  sure  to  measure  the  stone,  and  to  ascertain 
also  whether  a  lithotrite  can  readily  be  introduced  and 
manipulated.  The  instruments  required  are  a  stone-sound, 
lithotrites  (several  sizes,  Figs.  386-388),  an  evacuating-bulb 
and  tubes  (straight  and  curved,  Figs.  385,  389),  soft  catheters, 
a  glass  irrigator  to  inject  the  bladder,  and  instruments  in  case 
the  surgeon  is  forced  to  cut.  The^  patient  is  anesthetized 
and  is  placed  upon  his  back,  a  pillow  is  inserted  under 
the  pelvis  and  he  is  well  wrapped  up.  The  urine  is  drawn 
and  a  measured  amount  of  warm  boric  acid  is  allowed  to 
flow  into  the  bladder.  This  plan  is  better  than  having 
the  patient  retain  his  urine,  as  in  the  latter  case  there  is 
no  certainty  as  to  the  amount  of  fluid  in  the  viscus.     It  is 

well  to  introduce  at  least  five 
or  six  ounces  of  fluid  if  p^ds- 
sible.  If  the  bladder  will  not 
hold  four  ounces  the  opera- 
tion is  unsafe  (Thompson). 
The  lithotrite,  preferably  the 
instrument  of  Forbes  (Fig. 
388),  is  now  introduced, 
the  handle  being  gradually 
raised  to  a  vertical  posi- 
tion as  the  penis  is  drawn 
up  on  the  shaft,  but  not 
being  depressed  until  the 
instrument  has  passed  by  its 
own  weight  into  the  prostatic 
urethra.  Thompson's  plan 
for  catching  the  stone  is  as 
follows :  after  introducing 
the  lithotrite,  let  its  lower 
end  rest  for  a  few  seconds 
on  the  bottom  of  the  blad- 
der, so  that  currents  will 
subside  ;  then  draw  back  the 
male  blade,  wait  a  moment, 
close  the  blades,  and  in  almost  every  instance  the  stone 
will  be  caught.  If  the  stone  is  caught,  press  firmly  to  see  that 
the  calculus  is  well  held,  lock  the  instrument,  and  break  the 
foreign  body  by  screwing.  When  resistance  suddenly  ceases 
the  stone  has  either  slipped  or  has  been  crushed ;  if  crushed, 
the  blades  should  have  been  felt  forcing  through  the  stone 
and  the  calculus  should  have  been  heard  to  break.    When 


Fig.  389. — Thompson's  evacuator. 


OPERATIONS   ON   THE   BLADDER.  989 

resistance  ceases  catch  and  crush  again  as  above  directed. 
Rapid  movements  with  the  Hthotrite  are  improper,  as  they 
estabUsh  currents  which  are  apt  to  push  away  the  stone.    If 
the  above  maneuver  does  not  catch  the  stone,  see  if  the  cal- 
culus be  near  the  neck  of  the  bladder.     Pull  the  instrument 
close  to  the  vesical  neck,  and  open  it,  not  by  pulling  the  male 
blade,  but  by  pushing  the  female  blade.     If  the  operator  still 
fails  to  catch  the  stone,  or  if,  after  crushing,  a  large  fragment 
knocks  against  the  evacuator,  which  fragment  cannot  pass, 
conduct  a  careful  search  :  turn  the  blades  to  the  right  side, 
open,  and  close ;  then  to  the  left  side,  open,  and  close ;  next 
turn  the  point  around  behind  the  prostate,  open,  and  close. 
After   making   a   side   search   with    the    lithotrite,  turn    the 
instrument  very   slowly,  so    as    to    detect  the   catching  of 
the  bladder-wall  if  it  has  occurred,  and  crush  the  stone  m 
the  middle  of  the  bladder  with  the  blades  up.  After  crushmg 
several  times,  proceed  to  evacuate.     Fill  the  aspirator  with 
warm  saline  fluid.     Insert  an  evacuating  catheter,  its  point 
being  in  the  center  of  the  bladder,  let  the  fluid  and  fragments 
run  out  and  attach  the  aspirator  to  the  catheter ;  turn  the 
valve  and  compress  and  relax  the  bulb  so  that  an  ounce  or 
more'of  fluid  is  forced  in  at  each  squeeze,  the  compression 
coinciding    with    expiration.     The    debris  falls  into  a  bulb, 
and  the  pumping  is  continued  until  fragments  cease  to  pass, 
whereupon  the  point  of  the  catheter  is  pushed  against  the 
floor  of  the  bladder  and  another  trial  is  made.     If  fragments 
which  cannot  gain  exit  are  felt  knocking  against  the  tube, 
withdraw  the  evacuator,  crush  again,  and  again  use  the  aspi- 
rator    When  no  more  debris  comes  away  and  no  more  frag- 
ments are  felt,  withdraw  the  tube  and  carefully  sound  the 
bladder.     Keyes  advises  the  operator  to  seek  for  a  final  frag- 
ment by  listening  with  a  stethoscope  while  pumping  at  the 
bulb  and  searching  the  bladder  with  the  tube.    This  operation 
will  rarely  occupy  over  forty  minutes,  though  Bigelow  has 
protracted  it  for  three  hours,  the  patient  recovering.  A  seri- 
ous  complication  is  severe    bleeding,  due  to  damage  done 
with  the  instrument  or  to  the  presence  of  a  tumor  which 
easily  bleeds.    The  injection  of  moderately  hot  water  usually 
checks  hemorrhage,  but  if  bleeding  is  dangerous  m  amount 
the  operation  of   litholapaxy  should    be    abandoned  and  a 
suprapubic  lithotomy  be  performed. 

If  clogo-ing  of  the  lithotrite  with  fragments  occurs, 
forcible  pushing  of  the  blades  together  repeatedly  will 
probably  amend  it ;  but  it  will  never  happen  if  the  sur- 
geon uses  a  proper  form  of  instrument.     A  hthotrite  with  a 


990  DISEASES    OF   GENITO-URINARY  ORGANS. 

fenestrated  blade  will  not  lock.  Forbes's  lithoti-ite  is  a 
very  powerful  instrument,  the  blades  of  which  will  not  lock. 
If  the  blades  of  a  lithotrite  should  become  forcibly  and 
hopelessly  locked,  make  a  perineal  section,  clear  out  the 
blades,  close  them,  and  then  withdraw  the  instrument. 

After-treatment. — Put  the  patient  to  bed,  apply  a  bag  of 
hot  water  to  the  hypogastrium,  and  give  him  a  hypodermatic 
injection  of  morphin  as  he  recovers  from  ether.  Give  a  hot 
hip-bath  every  night,  and  administer  liquor  potassii  citratis 
in  moderate  doses  every  day.  If  urethral  fever  occurs,  use 
quinin  and  morphin,  wash  out  the  bladder  several  times  daily 
with  warm  boric-acid  solution,  and  tie  in  a  rubber  catheter. 
If  retention  occurs  use  the  catheter.  If  cystitis  appears, 
treat  as  in  an  ordinary  case.  The  urine  ceases  to  be  bloody 
in  two  or  three  days,  and  the  patient  may  get  up  in  a  week. 

Litholapaxy  in  Male  Children. — It  was  considered  until 
quite  recently  that  a  child,  because  of  the  small  size  of  its 
bladder,  the  small  diameter  of  the  urethra,  and  the  readiness 
with  which  the  mucous  membrane  is  lacerated  by  even 
slight  violence,  was  a  bad  subject  for  crushing.  Lateral 
lithotomy  is  known  to  be  eminently  successful  when  per- 
formed upon  children.  The  elder  Gross  did  this  operation 
upon  72  children  with  only  2  deaths.  Keegan,  however, 
has  persuaded  the  profession  that  rapid  lithotrity  is  per- 
fectly applicable  to  children :  he  shows  that  the  bladder 
of  a  child  of  even  less  than  two  years  of  age  is  quite  large 
enough  to  allow  the  surgeon  to  manipulate  an  instrument, 
that  the  mucous  membrane  is  in  no  danger  if  the  operator 
be  careful,  and  that  the  urethra  is  by  no  means  so  sm.all  as 
was  supposed.  The  urinary  meatus  must  often  be  incised, 
and  after  doing  this,  Keegan  states,  there  can  be  passed  in 
a  boy  of  from  three  to  six  years  a  No.  7  or  8  lithotrite 
(English),  and  in  a  boy  of  from  eight  to  ten  years  a  No.  10 
or  even  a  No.  14.  It  is,  however,  just  to  state  that  the 
operation  is  more  delicate  than  a  like  procedure  on  older 
persons,  and  that  no  one  is  justified  in  doing  it  who  has  not 
had'  considerable  experience  in  adult  cases.  Furthermore, 
it  should  be  noted  that  Keegan's  mortality  by  this  operation 
has  been  4.3  per  cent.,  while  Gross's  mortality  from  lateral 
lithotomy  on  children  was  2.67  per  cent. 

Special  points  of  Litholapaxy  on  male  children  are  as  fol- 
lows :  use  well-fenestrated  lithotrites  ;  have  a  stylet  to  punch 
out  the  fragments  blocking  the  evacuator;  and  crush  the 
stone  to  a  fine  mass.  There  can  usually  be  employed  a  No, 
8  lithotrite  and  a  No.  8  evacuatinsr-tube. 


OPERATIONS    ON   THE   BLADDER.  99 1 

Perineal  Lithotrity  (Keith's  Operation). — This  operation 
is  employed  by  some  surgeons  in  deaHng  with  very  hard  or 
very  large  calculi  in  male  adults,  or  in  cases  in  which  it  is 
impossible  to  introduce  a  lithotrite  into  the  bladder.  Keith's 
operation  consists  in  opening  the  urethra  from  the  peri- 
neum, passing  a  lithotrite  through  the  wound,  into  the  ure- 
thra and  along  the  urethra  into  the  bladder,  and  crushing 
the  stone,  introducing  an  evacuator  and  removing  the 
fragments.  In  Keith's  operation  the  incision  is  median, 
and  opens  the  membranous  urethra.  In  very  large  stones, 
Milton  thinks  the  surgeon  should  open  the  bladder  as  in 
ordinary  lateral  lithotomy,  introduce  a  lithotrite  through 
the  incision,  and  crush  the  stone  before  extracting  it, 
thus  avoiding  the  infliction  of  injury  upon  important  struct- 
ures. 

Operation  for  Stone  in  "Women. — If  the  stone  be  small, 
give  the  patient  ether,  place  her  in  the  lithotomy  position, 
dilate  the  urethra  with  the  uterine  dilator  until  it  admits  the 
index-finger,  and  remove  the  stone  with  the  finger,  the 
scoop,  or  the  forceps.  If  the  stone  is  found  to  be  too  large 
to  pass,  crush  it  with  a  lithotrite  and  get  rid  of  the  debris 
by  the  evacuator.  Large  stones  (two  ounces)  may  require 
suprapubic  lithotomy.  Vaginal  lithotomy  is  never  required. 
If  done,  it  is  very  likely  to  leave  as  a  legacy  a  vesicovaginal 
fistula.  In  female  children  dilate  the  urethra,  crush  the 
stone,  and  evacuate. 

Cystotomy. — This  term  means  the  opening  of  the  bladder, 
and  it  is  usually  applied  to  an  opening  made  for  drainage, 
for  diagnosis,  for  the  removal  of  stones  or  tumors,  or  for 
"the  treatment  of  ulcers.  This  opening  may  be  done  by  (i) 
a  suprapubic  cut  (as  in  suprapubic  lithotomy),  (2)  a  lateral 
perineal  cut  (as  in  lateral  lithotomy),  or  (3)  a  median  perineal 
cut  (as  in  median  lithotomy). 

The  operation  may  be  completed  in  one  sitting,  or  the 
bladder  may  be  only  exposed,  the  opening  of  it  being  delayed 
for  several  days  until  it  becomes  adherent  to  the  margins  of 
the  wound  (Senn's  operation).  Senn's  operation  prevents 
infiltration  of  urine  into  the  prevesical  space,  and  it  is  advisa- 
ble to  select  it  if  the  urine  is  very  foul. 

A  sinus  may  persist  after  suprapubic  cystotomy,  but  usu- 
ally the  wound  heals  unless  it  is  kept  open  by  some  expe- 
dient. 

The  effects  of  suprapubic  drainage  are  very  beneficial  in 
cases~of  chronic  cystitis  associated  with  hypertrophy  of  the 
prostate  gland,  the  urine  being  foul.     Drainage  causes  the 


992 


DISEASES   OF  GENITO-URINARY  ORGANS. 


urine  to  become  clear  and  the  mucous  membrane  of  the 
bladder  to  become  normal.  If  the  opening  is  made  as  a 
permanent  drain,  there  will  usually  be  incontinence,  as  the 
new  channel  has  no  sphincter  action  (Dandridge). 

Suprapubic  Cystotomy. — The  operation  is  employed  to 
allow  the  surgeon  to  explore  the  bladder,  to  treat  an  ulcer, 
to  provide  drainage,  or  to  remove  a  tumor.  If  the  opera- 
tion   is   for   calculi,  it  is    known    as    suprapubic    lithotomy 


Fig.  390. — Thompson's  vesical  forceps  for  removing  growths  in  the  bladder  :  for  growths 
close  to  the  neck  of  the  bladder,  with  separation  of  the  blades,  to  avoid  nipping  the  neck 
of  the  bladder. 


(page  983).  After  the  bladder  is  opened  its  interior  can  be 
illuminated  by  the  rays  of  an  electric  lamp,  which  appliance 
is  fastened  with  a  mirror  to  the  forehead  of  the  operator. 
The  operation  is  described  on  page  983.  If  an  ulcer  is  found, 
it  is  scraped  with  a  curet  or  a  spoon.  Most  cases  of  turnor 
require  suprapubic  cystotomy.  It  is  true  that  a  small  single 
growth  at  the  vesical  neck  is  accessible  by  median  cyst- 
otomy, but  the  area  for  manipulation  is  very  narrow  and  the 


OPERATIO^NS    ON   THE   BLADDER. 


993 


growth  cannot  be  seen.  Every  large  growth,  all  cases  of 
multiple  tumors,  and  all  cases  of  tumor  in  individuals  with 
great  depth  of  perineum  or  with  enlarged  prostate  require 


Fig.  391. — Senn's  silver  tube. 


suprapubic  cystotomy,  an  operation  which  allows  one  to  feel 
and  to  see  the  growth,  which  gives  room  for  manipulation, 
and  which  permits  thorough  exploration  of  the  entire  blad- 


FiG.  392. — Senn's  tube  applied.     The  instrument  does  not  press  upon  the  sensitive  neck  of 

the  bladder. 

der.  The  patient  is  put  in  the  Trendelenburg  position  if 
water  distention  is  used,  but  is  placed  horizontally  if  air 
distention  is  employed.  After  opening  the  bladder  as  for 
stone  (page  983)  hold  the  edges  of  the  incision  apart  by 

63 


994  DISEASES    OF   GENirO-UREVA  RY   OR  CANS. 

means  of  a  speculum  (speculum  of  Keen  or  Watson)  or 
with  retractors,  and  reflect  the  electric  light  into  the  wound. 
Growths  when  seen  can  be  twisted  off,  a  pair  of  forceps 
holding  the  base  and  another  pair  being  used  to  twist. 
Broad  growths  should  be  transfixed,  ligated,  and  severed. 
Some  growths  (as  cancer)  are  removed  piece  by  piece  with 
Thompson's  forceps  (Fig.  390),  the  base  of  the  tumor  being 
scraped.  Soft  growths  are  scraped  away  with  a  curet,  a 
spoon,  or  a  finger-nail.  If  bleeding  is  severe,  check  it  by 
pressure,  by  iced  water,  or  even  by  the  actual  cautery.  In 
some  cases  the  wound  is  allowed  to  heal  rapidly.  In  others 
the  bladder  is  drained  for  a  considerable  time.  In  some  it 
is  kept  open  permanently.  Permanent  drainage  is  desirable 
in  some  cases  of  enlarged  prostate,  and  in  such  cases  Senn's 
tube  is  very  useful  (Fig.  391). 

Median  Cystotomy. — The  same  incision  is  made  in  the 
perineal  raphe  in  median  cystotomy  as  for  median  lithot- 
omy. A  grooved  staff  is  introduced  and  is  hooked  up 
under  the  pubes  ;  an  incision  is  made  into  the  membranous 
urethra,  and  is  extended  backward  for  three-quarters  of  an 
inch,  and  a  finger  is  carried  into  the  bladder.  If  searching 
for  a  growth,  find  it  with  the  finger,  catch  it  wdth  Thomp- 
son's forceps,  and  twist  it  off.  Soft  growths  can  be  scraped 
away.  Stop  bleeding  by  digital  pressure  or  by  injections  of 
iced  water.  If  median  cystotomy  does  not  allow  access  to 
the  tumor,  perform  suprapubic  cystotomy. 

Growths  in  the  Female  Bladder. — Dilate  the  urethra  as 
in  a  case  of  stone,  and  scrape,  twist,  or  pull  the  growth  away 
or  ligate  it.  If  the  growth  is  large  or  if  there  are  multiple 
growths,  perform  suprapubic  cystotomy. 

Diseases  and  Injuries  of  the  Urethra,  Penis,  Testicles, 
Prostate,  Seminal  Vesicles,  Spermatic  Cord,  and 
Tunica  Vaginalis. 

Injuries  of  the  penis  and  urethra  may  arise  from  trau- 
matism to  the  perineum  or  the  penis,  from  cuts  and  twists 
of  the  penis,  from  the  popular  "  breaking "  of  a  chordee, 
from  tying  strings  around  the  organ,  from  forcing  rings  over 
it,  from  the  passage  of  instruments,  or  from  the  impaction 
of  calculi.  Violence  inflicted  upon  an  erect  penis  may  fract- 
ure the  corpora  cavernosa.  The  writer  saw  one  man  with  a 
glass  rod  broken  off  in  the  canal,  he  having  been  in  the 
habit  of  introducing  it  at  the  dictate  of  morbid  sexual  ex- 
citement.    A  patient  in  the  Insane  Department  of  the  Phila- 


RCPTC'RE    OF   THE    URETHRA.  995 

dolphia  Hospital  pushed  a  ring  over  his  penis,  which  organ 
was  lacerated  into  the  urethra.  These  injuries  are  treated 
on  general  principles. 

Perineal  Bruises. — If  the  perineum  be  bruised  without 
rupture  of  the  urethra,  the  perineum  and  scrotum  swell  and 
become  discolored ;  water  is  passed  with  difficult}*  because 
the  extravasated  mass  of  blood  in  the  peri-urethral  tissues 
occludes  more  or  less  the  canal ;  the  water  is  not  bloody ; 
and  there  are  pain  and  profound  shock.  Some  authors  desig- 
nate as  rupture  those  cases  in  which  laceration  of  the  spongy 
tissue  occurs,  without  involvement  of  the  mucous  membrane 
or  of  the  fibrous  coat,  but  they  are  properly  contusions. 

Treatment. — Place  the  patient  in  bed  and  establish  reac- 
tion, and  when  reaction  is  complete  employ  opiates  for  the 
relief  of  pain.  Apply  an  ice-bag  to  the  perineum.  If,  not- 
withstanding these  measures,  swelling  continues,  introduce 
a  silver  catheter  (No.  12  English),  tie  it  in,  and  make  press- 
ure upon  the  perineum  by  a  firmly-applied  T-bandage  or 
by  a  crutch  braced  against  the  foot-board  of  the  bed.  Even 
when  swelling  is  slight,  retention  of  urine  may  occur  from 
projection  of  a  submucous  blood-clot  into  the  canal  of  the 
urethra.  In  some  cases  it  may  become  necessary  to  incise 
and  evacuate  the  blood-clot.  After  twenty-four  hours  have 
passed,  if  hemorrhage  has  ceased,  substitute  a  hot-water 
bag  for  the  ice-bag,  and  empty  the  bladder  regularly  with 
a  soft  catheter.  Occasionally,  though  rarely,  an  abscess 
forms.  Punctured  zvounds  of  tJic  nirthra  require  ordinary 
dressings.  Incised  ivonnds  of  tJic  urethra,  when  longitudinal, 
are  closed  by  suture.  Healing  is  rapid,  and  ill  consequences 
are  not  to  be  feared.  Stricture  does  not  follow.  When  the 
wound  is  transverse,  introduce  a  catheter,  suture  the  wound 
over  the  instrument,  and  remove  the  catheter  at  the  end  of 
the  third  day.  If  a  catheter  cannot  be  introduced,  employ 
sutures,  but  at  the  first  evidence  of  extravasation  open  the 
wound,  and  if  drainage  is  not  free  perform  an  external  peri- 
neal urethrotomy. 

Rupture  of  the  Urethra. — B)-  this  term  is  meant  a 
lacerated  or  a  contused  wound  of  the  urethra,  destroying 
partially  or  entirelx'  the  integrity  of  the  canal.  A  lacerated 
wound  may  be  induced  by  fracture  of  the  cavernous  bodies 
during  erection,  the  symptoms  being  severe  hemorrhage, 
intense  pain,  retention  of  urine,  and  inability  to  pass  an 
instrument;  infiltration  of  urine  occurs,  and  gangrene  is  a 
common  result.  The  writer  has  seen  one  case  of  rupture 
of  the  penile  urethra  due  to  a  man's  slipping  while  shaving, 


996  DISEASES    OF   G EXITO-L'R IXA R  V   ORGANS. 

the  penis  being  caught  in  a  partially  open  drawer,  the 
drawer  being  shut  by  his  body  coming  against  it.  Rupture, 
however,  is  almost  invariably  located  in  the  perineum,  and  it 
arises  when  the  urethra  is  suddenly  and  forcibly  pressed 
against  the  arch  of  the  pubes  by  a  blow,  by  a  kick,  or  by 
falling  astride  a  beam  or  a  fence-rail.  The  lesion  of  urethral 
rupture  consists  in  some  cases  of  laceration  of  the  spongy 
tissue  and  the  mucous  membrane,  a  cavity  being  formed 
which  communicates  with  the  canal,  and  which  fills  with 
urine  during  micturition.  In  other  cases  not  only  the  spongy 
tissue  and  the  urethral  mucous  membrane  are  rent  asunder, 
but  the  fibrous  coat  is  also  torn,  the  canal  opening  directly 
into  the  perineal  tissues,  among  which  a  huge  cavity  forms, 
that  fills  with  blood  and  later  with  urine  and  pus.  The 
urethra  may  be  torn  entirely  across,  but  in  most  cases  a 
small  portion  at  least  of  its  circumference  is  uninjured. 
Rupture  never  occurs  primarily  and  alone  in  the  prostatic 
urethra;  it  is  extremely  rare  in  the  membranous  urethra 
unless  due  to  pelvic  fracture;  and  it  is  very  unusual  in  the 
penile  urethra.  The  seat  of  rupture  in  the  great  majority 
of  cases  is  in  the  region  of  the  bulb.  Very  rarely  is  the  skin 
broken.  Retention  of  urine  due  to  stricture  may  lead  to 
extravasation  of  urine. 

Symptoms. — The  symptoms  of  rupture  of  the  urethra 
are  considerable  pain,  aggravated  by  motion,  pressure,  and 
attempts  to  pass  water;  great  shock;  in  some  cases  mictu- 
rition is  still  possible,  blood  preceding  and  also  discoloring 
the  stream,  for  some  blood  usually  runs  into  the  bladder ; 
retention  of  urine  quickly  arises;  in  a  vast  majority  of  the 
cases  retention  is  absolute  from  the  very  first,  and  it  is  due 
to  the  interruption  in  the  integrity  of  the  canal  and  to  the 
occlusion  of  the  channel  by  blood-clots.  Bleeding,  which  is 
usually  free,  lasts  for  several  hours,  some  little  blood  gener- 
ally appearing  externally  and  much  being  retained  in  the 
perineum,  inducing  progressive  swelling.  The  presence  of  a 
large  swelling  is  regarded  as  evidence  of  urethral  rupture. 
The  blood  which  is  effused  in  the  perineum  may  extend 
under  the  fascia  to  the  penis  and  scrotum.  The  swelling 
soon  becomes  reddish,  purple,  or  even  black,  pressure  upon 
it  is  apt  to  cause  blood  to  run  from  the  meatus,  and  it  is  aug- 
mented in  volume  when  attempts  are  made  to  urinate. 
After  a  time,  if  the  surgeon  does  not  act,  the  urine  fills 
the  perineal  cavity  and  widely  infiltrates,  and  there  ensue 
gangrene,  sloughing,  and  sepsis,  life  being  endangered  or 
fistulae  being  left  as  legacies.     The  course  of  the  extravasated 


RUPTURE    OF    TIIK    URKTJIRA.  997 

urine  will  often  enable  one  to  locate  the  scat  of  injury.  In 
rupture  of  the  membranous  urethra,  if  uncomplicated,  the 
urine  remains  between  the  two  layers  of  the  triangular  liga- 
ment until  a  channel  is  opened  for  it  by  sloughing  or  by  the 
knife.  When  extravasation  occurs  behind  the  posterior 
layer  of  the  ligament  the  urine  finds  its  way  to  the  peri- 
neum in  the  neighborhood  of  the  anus.  When  the  rupt- 
ure is  in  front  of  the  anterior  layer  of  the  ligament  the  urine, 
directed  by  the  deep  layer  of  the  superficial  fascia,  finds  its 
way  into  the  scrotum  and  up  on  the  belly,  but  does  not  pass 
into  the  thighs.  A  contusion  is  distinguished  from  a  rupt- 
ure by  the  facts  that  in  the  former  the  perineal  swelling  is 
not  very  extensive  and  does  not  enlarge  on  attempting  mic- 
turition, while  in  the  latter  it  is  extensive  and  does  enlarge 
on  attempting  to  pass  water.  Furthermore,  contusion  does 
not  cause  urethral  hemorrhage,  while  rupture  does.  A 
contusion  sometimes,  but  not  often,  prevents  the  passage  of 
a  catheter;  a  rupture  almost  always,  but  not  invariably,  does 
so.  The  mortality  from  severe  rupture  with  extravasation 
is  about  14  per  cent.  (Kaufman). 

Treatment. — In  some  cases  it  is  possible  to  suture  the 
urethra,  and  this  procedure  should  be  carried  out  when  pos- 
sible. In  order  to  suture,  perform  suprapubic  cystotomy  and 
also  make  a  perineal  section.  Find  the  posterior  end  of  the 
ruptured  urethra  by  passing  a  catheter  from  the  bladder  into 
the  urethra.  Suture  with  silk.  The  sutures  pass  through  all 
of  the  coats  of  the  urethra.  The  roof  of  the  canal  is  sutured 
first,  then  a  steel  sound  is  introduced  from  the  meatus,  and 
the  urethra  is  sutured  around  the  instrument.  The  sound 
is  withdrawn  and  the  bladder  is  drained  by  Cathcart's  siphon 
as  modified  by  Keen.^  In  recent  cases  of  ruptured  urethra 
the  usual  treatment  is  as  follows  :  immediately  perform  peri- 
neal section  and  turn  out  the  clot;  trim  off  lacerated  edges; 
find  the  proximal  end  of  the  urethra,  pass  a  catheter  from 
the  meatus  into  the  bladder,  and  leave  it  in  situ  until  healing 
has  begun  around  it.  When  rupture  occurs  back  of  a  strict- 
ure it  is  a  good  plan  to  excise  the  cicatricial  tissue.  In  cases 
with  extravasation  lay  open  freely  all  pockets  of  urine  and 
proceed  as  above.  If  the  proximal  end  of  the  urethra  can- 
not be  found,  either  open  the  bladder  by  Cock's  method  of 
perineal  section  without  a  guide,  cutting  toward  the  apex  of 
the  prostate  gland  and  carrying  the  incision  forward  into 
the  rent,  or  perform  a  suprapubic  cystotomy  with  retrograde 
catheterization ;  that  is,  push  an  instrument  from  the  bladder 

^  See  Weir's  report  in  Medical  Record,  May  9,  1896. 


998  DISEASES    OE   GENITO-URINARY  ORGANS. 

into  the  wound,  and  use  it  to  guide  a  catheter  passed  from 
the  meatus  into  the  bladder.  The  wound  is  packed  with 
iodoform  gauze,  and  the  bowels  are  tied  up  with  opium  for 
a  few  days.  Many  surgeons  strongly  disapprove  of  the 
custom  of  retaining  the  catheter,  believing  that  the  instru- 
ment does  no  real  good,  as  urine  is  certain  to  get  between 
the  catheter  and  the  walls  of  the  urethra.  In  fact,  it  is  quite 
enough  to  stuff  the  wound  with  gauze,  the  patient  urinating 
through  the  wound  for  the  first  few  days,  after  which  time  a 
catheter  is  used  at  regular  intervals.  Whatever  method  is 
employed,  healing  will  require  from  six  to  eight  weeks,  and 
the  patient  must  during  the  rest  of  his  life,  from  time  to  time, 
introduce  large-sized  bougies. 

Foreign  Bodies  in  the  Urethra. — These  bodies  may 
be  calculi,  bodies  introduced  by  injury,  as  shot,  bone,  etc., 
bodies  entering  from  a  fistulous  opening  into  the  rectum,  or 
bodies  introduced  from  the  meatus,  as  broken  bits  of  cathe- 
ters, straws,  pins,  etc. 

The  symptoms  vary  with  the  size  and  the  nature  of  the 
body.  Sometimes  there  are  almost  no  symptoms ;  at  other 
times  there  are  found  great  pain,  retention  of  urine,  and 
hemorrhage.  Examination  is  made  by  feeling  carefully  with 
a  finger  in  the  rectum  and  by  searching  very  gently  with 
a  sound,  taking  care  not  to  push  the  body  back.  If  the 
bladder  is  well  filled  with  water  when  the  body  becomes 
impacted,  inject  a  little  oil  into  the  meatus,  close  the  lips 
with  the  fingers,  and  direct  the  patient  to  forcibly  attempt 
urination,  the  surgeon  opening  the  meatus  when  the  urethra 
is  widely  distended,  the  foreign  body  being  often  forced  out. 
If  this  maneuver  fails,  and  the  foreign  body  is  impacted  in 
the  pendulous  urethra,  prevent  its  backward  passage  by  at 
once  tying  a  rubber  tube  around  the  penis.  Try  to  squeeze 
the  body  out,  and,  if  unsuccessful,  endeavor  to  catch  it  with 
a  wire  loop,  with  a  scoop,  or  with  the  long  urethral  forceps. 
If  these  methods  fail,  cut  down  upon  the  body  and  remove 
it,  dividing  any  existing  stricture.  If  a  hairpin  is  in  the 
canal,  the  feet  of  the  pin  are  almost  always  pointing  to  the 
meatus;  to  prevent  them  catching  on  attempted  withdrawal, 
the  penis  must  be  squeezed  to  approximate  the  feet,  and 
when  they  are  adjacent  a  part  of  a  silver  catheter  is  slipped 
over  to  retain  them  in  this  position,  when  the  pin  can  be 
extracted.  If  this  fails,  drag  the  penis  against  the  belly,  by 
rectal  touch  force  the  sharp  ends  out  through  the  integu- 
ment, cut  one  end  off,  and  then  withdraw  the  other.  An 
ordinary  large-headed  pin   is  forced  out  in  the  same  way, 


L'RETIIKITIS.   OR  IXFLAMMATION  OF  THE  URETHRA.    999 

and  when  the  head  is  turned  extcrnalh'  it  is  extracted 
from  the  meatus.  If  a  Hthotrite  loaded  with  fragments 
be  caught  in  the  urethra,  the  surgeon  must  perform  a 
perineal  section,  clean  and  close  the  blades,  and  withdraw 
the  instrument. 

Urethrorrhea  is  not  urethral  mflanniiation,  but  is  a  con- 
dition of  sensitiveness  of  the  urethra  and  oversecretion  of 
the  glandular  elements.  It  may  be  due  to  masturbation, 
sexual  excess,  and  also,  as  Sturgis  points  out,  to  withdrawal 
eiuring  sexual  intercourse,  and  to  ungratified  sexual  passion. 
A  drop  or  two  of  transparent  mucus  is  found  at  the  meatus 
in  the  morning,  and  a  considerable  amount  may  flow  away 
while  straining  at  stool  or  upon  the  diminution  of  an  erec- 
tion. This  flow  at  stool  is  often  called  defecation  spermator- 
rhea. This  discharge  stains  but  does  not  stiffen  linen  (Sturgis). 
The  discharge  contains  mucus,  mucous  corpuscles,  epithe- 
lial cells,  sometimes  spermatozoids,  but  no  gonococci  or  pus 
organisms.  The  patient  may  be  well  in  all  other  respects  ; 
there  may  be  neurasthenic  symptoms,  sexual  weakness,  or 
even  impotence. 

Treatment. — In  an  uncomplicated  case  improvement  or 
cure  will  follow  upon  the  abandonment  of  evil  habits.  If 
complications  arise,  the}^  must  be  treated. 

Uretliritis,  or  Inflammation  of  the  Urethra. — Ure- 
thral inflammations  can  be  divided  into  two  classes:  (i) 
simple,  in  which  infection  is  due  alone  to  pyogenic  cocci, 
and  (2)  specific,  in  which  the  gonococcus  is  present. 

Simple  urethritis  ma\'  be  due  to  several  causes,  such  as 
traumatism;  great  acidity  of  the  urine;  chancre  in  the  ure- 
fh"ra;  contact  with  menstrual  fluid,  leukorrheal  discharge, 
the  "discharge  from  malignant  disease  of  the  uterus,  ordinary 
pus,  or  acrid  vaginal  discharge  ;  the  passage  of  instruments  ; 
the  administration  of  irritant  diuretics;  strong  injections; 
worms  in  the  rectum ;  a  febrile  malady ;  venereal  excess 
and  masturbation;  and  the  passage  or  impaction  of  for- 
eign bodies.  A  temporary  and  mild  urethritis  sometimes 
accompanies  early  syphilitic  eruptions.  Simple  urethritis 
is  less  severe  and  prolonged  than  gonorrheal  urethritis, 
-though  clinically  in  the  early  stage  the  physician  cannot 
invariably  distinguish  between  the  two  forms.  The  gono- 
coccus is  never  found  in  the  discharge  of  simple  urethritis. 
In  the  non-specific  inflammation  pus  is  not  always  present, 
many  cases  stopping  short  of  pus-formation  after  a  varying 
period  of  catarrh,  but  any  catarrh  ma}'  become  purulent. 
A  simple  urethritis  may  be  caused  or  may  be  prolonged  for 


lOOO         DISEASES    OF   GENITO-URINARY   ORGANS. 

an  indefinite  period  by  the  presence  of  large  amounts  of 
oxalate  in  the  urine  or  the  existence  of  the  urrc-acid  diathesis 
(see  Gouty  Urethritis). 

Treatment. — Seek  for  the  cause  and  remove  it.  Correct 
any  abnormal  condition  of  the  urine  by  means  of  suitable 
diet,  drugs,  and  mode  of  life.  Mild  astringent  injections 
are  useful.  It  may  be  necessary  to  flush  the  urethra  repeat- 
edly with  a  solution  of  silver  nitrate  (i  :  8000). 

Traumatic  Urethritis. — The  pain  in  traumatic  urethritis 
is  coincident  with  the  introduction  of  the  foreign  body.  The 
discharge,  which  may  be  bloody,  mucous,  mucopurulent,  or 
purulent,  comes  on  within  twenty-four  hours. 

Treatment. — If  the  inflammation  is  slight,  prescribe  diluent 
drinks,  paregoric,  and  a  saline.  If  severe,  put  the  patient  to 
bed,  apply  hot  fomentations  to  the  perineum,  give  diluent 
drinks,  employ  suppositories  of  opium  and  belladonna,  and 
watch  for  fever  and  other  complications. 

Gouty  Urethritis. — This  condition  first  manifests  itself  in 
the  posterior  urethra,  not  in  the  anterior,  as  d^es  clap.  Its 
symptoms  are  great  vesical  irritabilit>' ;  pain  on  urination; 
discharge  usually  scanty,  associated  with  uric  acid  in  the 
urine  or  other  symptoms  of  gout.  The  treatment  comprises 
dieting  and  the  usual  remedies  for  gout.  Purgatives  are 
given  freely,  and  full  doses  of  colchicum,  piperazin,  urotropin, 
or  the  alkalies ;  hot  baths,  low  diet,  diluent  drinks,  and 
diaphoretics  are  indicated.  A  chronic  discharge  from  the 
prostatic  region  is  apt  to  linger ;  for  this  there  is  nothing 
better  than  the  usual  gouty  remedies  and  saline  waters  with 
copaiba,  cubebs,  or  sandalwood  oil.  In  many  cases  it  is 
necessary  to  flush  the  urethra  once  a  day  with  a  solution 
of  silver  nitrate  (i  :  8000). 

Eczematous  Urethritis. — Berkley  Hill  states  that  this 
disease  is  very  obstinate,  is  probably  associated  with  gout, 
and  is  met  with  in  adults  of  full  habit  or  Avho  are  beer- 
drinkers  and  who  have  eczema  of  the  surface  of  the  body. 
He  states  also  that  the  glans  penis  near  the  meatus  is  red 
and  tender,  and  that  the  interior  of  the  urethra  is  in  the 
same  condition.  Pain  is  constant,  and  it  is  aggravated  on 
micturition.  The  discharge  is  scanty.  The  treatment  com- 
prises injections  of  cold  water  or  irrigation  with  iced  watex, 
and  internally  the  administration  of  arsenic  with  the  alkalies. 

Tubercular  urethritis  is  due  to  a  tubercular  ulcer,  which 
is  most  apt  to  be  seated  near  the  vesical  neck.  There  is  a 
little  pain  on  micturition,  but  there  is  intense  pain  at  one 
spot  on  passing  a  bougie.     The  discharge  is  slight  and  at 


GONORRHEA.  lOOI 

times  bloody.  The  bladder  is  very  irritable,  and  severe 
cystitis  arises  and  persists.  The  trcatDiciit  includes  warmth, 
good  food,  and  cod-liver  oil,  removal  to  an  equable  climate, 
and  living  as  much  as  possible  out  of  doors.  The  bladder 
is  washed  out  once  a  day  with  boric-acid  solution.  Iodo- 
form emulsion  is  injected  daily,  but  after  a  time  the  surgeon 
will  be  forced  to  drain  by  perineal  or  suprapubic  cystotomy. 

Gonorrhea  (Clap  ;  Specific  Urethritis ;  Tripper ; 
Venereal  Catarrh). — Gonorrhea  is  an  acute  inflannnation 
of  the  genital  mucous  membrane,  of  venereal  origin,  due  to 
the  deposition  and  multiplication  of  gonococci  in  the  cells 
of  the  membrane  and  a  mixed  infection  with  the  cocci  of 
suppuration.  In  the  male,  clap  begins  within  the  meatus 
and  fossa  navicularis  and  extends  backward  throughout  the 
length  of  the  urethra.  The  mucous  membrane  swells  and 
becomes  hyperemic,  and  there  is  a  discharge,  first  of  mucus 
and  serum,  and  then  of  pus.  In  severe  cases  the  discharge 
is  bloody  (black  gonorrhea).  For  a  week  or  more  the  in- 
flammation increases,  then  becomes  stationary  for  a  time, 
and  then  declines,  the  discharge  growing  less  profuse  and 
thinner,  a  watery  discharge  lasting  for  some  little  time. 
An  ordinary  case  of  genuine  gonorrhea  lasts  from  six  to  ten 
weeks,  and  even  a  case  limited  purely  to  the  anterior  urethra 
will  rarely  be  cured  within  four  or  five  weeks.  During  the 
acute  stage  the  entire  penis  swells  and  the  corpus  spongi- 
osum becomes  infiltrated  with  inflammatory  exudate. 
Gonorrhea  may  produce  .systemic  complications  and  tends 
particularly  to  attack  serous  membranes  or  other  endothelial 
structures  (joints,  pericardium,  pleura,  tendon-sheaths, 
intima  of  vessels,  etc.). 

Gonorrheal  rheumatism  is  discussed  on  page  530.  Gonor- 
rheal peritonitis  is  rare.  Infection  of  the  peritoneum  through 
the  blood  is  very  rare.  Tlie-ina^cadty^of  cases  of  gonorrheal 
peritonitis  occur  in- women  and  are  due  to  directextension 
from  the  Fallopian  tubes.  Gonococci  have  not  been  found 
in  the  exudates  of  cases  of  pleuritis  and  pericarditis  sup- 
posed to  be  of  gonorrheal  origin.  Gonococci  have  never 
been  found  in  meningitis.  True  gonorrheal  septicemia  occa- 
sionally occurs.  In  one  case  Blumer  and  Hayes  found  the 
organisms  in  the  blood. 

Symptoms  of  Acute  Inflammatory  Gonoi-rhca. — The  period 
of  incubation  of  gonorrhea  is  from  a  few  hours  to  two 
weeks.  The  patient  notices  on  arising  a  drop  of  thin  fluid 
which  glues  together  the  lips  of  the  meatus,  and  he  feels 
some  pain   on    urination.     The   meatus  is  red  and  swollen. 


I002  DISEASES    OF   GENITO-URINARY   ORGANS. 

Within  forty-eight  hours  the  first  stage,  or  the  stage  of 
increase,  becomes  estabhshed.  The  meatus  is  now  red, 
swollen,  and  everted  (fish-mouth  meatus) ;  micturition  causes 
severe  pain* (ardor  urina;) ;  chordee  occurs,  especially  when 
the  patient  is  warm  in  bed.  By  chordee  we  mean  a  condition 
of  painful  erection  in  which  the  penis  is  markedly  bent.  The 
rigid  infiltration  of  the  corpus  spongiosum  prevents  it  dis- 
tending to  accommodate  itself  to  the  enlarged  corpora  caver- 
nosa, and  in  consequence  the  organ  curves.  There  is  frequent 
micturition  with  tenesmus,  and  a  profuse  discharge  which  is 
yellow,  greenish,  or  even  bloody.  The  complications  of  this 
stage  are  /^^?/rt////'/V  (inflammation  of  the  mucous  membrane  of 
the  glans  penis),  baianapasthitis  (inflammation  of  the  surface  of 
the  glans  and  the  mucous  membrane  of  the  prepuce), p/imiosis 
(thickening  and  contraction  of  the  foreskin  so  that  the  glans 
cannot  be  uncovered),  and  parapliimosis  (catching  and  fixa- 
tion of  the  retracted  prepuce  behind  the  corona  glandis). 
In  the  second  or  stationary  stage,  which  lasts  from  the  end 
of  the  first  to  the  end  of  the  second  week,  the  acute  symp- 
'toms  of  the  first  stage  continue.  The  complications  of 
this  stage  are  peri-urethral  abscess,  lymphangitis,  solitary 
and  painful  bubo  of  the  groin  which  may  suppurate,  inflam- 
mation of  Cowper's  glands,  inflammation  of  the  prostate  or 
of  the  bladder,  and  gonorrheal  ophthalmia.  In  the  tJiird  or 
subsiding  stage  the  symptoms  gradually  abate,  the  discharge 
becoming  scantier  and  thinner,  and  finally  drying  up.  This 
stage  is  of  uncertain  duration,  and  in  it  there  may  occur 
epididymitis,  or  inflammation  of  the  epididymis.  Among 
other  possible  complications  we  may  mention  gonorrheal 
arthritis  (page  530),  infective  endocarditis,  tenosynovitis, 
pyelitis,  perichondritis,  and  peritonitis.  Every  urethral  dis- 
charge should  be  examined  for  gonococci  in  order  to  make 
a  positive  diagnosis.  This  examination  is  made  several 
times  during  the  progress  of  the  case,  so  as  to  determine 
when  the  organisms  disappear.  The  examination  can  be 
easily  made.  Place  a  drop  of  discharge  upon  a  cover-glass, 
lay  another  cover-glass  over  this,  and  slide  the  glasses 
apart.  Dry  the  slides  in  the  flame  of  an  alcohol  lamp. 
Bring  the  cover-glasses  in  contact  with  a  saturated  solution 
of  methylene-blue  in  5  per  cent,  carbolic-acid  water.  The 
staining-material  is  allowed  to  remain  in  contact  with  the 
slides  for  five  or  ten  minutes,  the  glasses  are  washed  with 
water,  are  then  placed  in  a  solution  of  5  drops  of  acetic  acid 
to  20  c.c.  of  water,  and  kept  there  "  long  enough  to  count 
one,  two,  three  slowly,"  and  again  washed  with  water.     Ex- 


CHROXIC   URETHRAL   DISCHARGES.  IOO3 

amination  with  the  microscope  shows  the  i^onococci  stained 
blue.^ 

Subacute  or  catarrhal  gonorrhea  develops  in  men  who 
have  pre\iousl}-  had  gonorrhea,  as  a  result  of  prolonged  or 
repeated  coition  or  of  contact  with  menstrual  fluid  or  leukor- 
rheal  discharge.  There  is  profuse  mucopurulent  discharge, 
ver)'  little  pain  on  micturition,  rarely  chordee  or  marked 
irritabilit}"  of  the  bladder. 

Irritative  or  Abortive  Gonorrhea. — In  this  disease  the 
.symptoms,  which  are  identical  with  those  of  beginning  clap, 
do  not  increase,  but  are  apt  to  disappear  within  ten  da}'s. 

Chronic  Urethral  Discharges. — Chronic  Urethral 
Catarrh,  which  may  follow  gonorrhea,  is  characterized  b}- 
the  occasional  presence  of  a  drop  of  clear,  tenacious  liquid. 
This  discharge  becomes  more  profuse  as  a  result  of  sexual 
excitement  or  the  abuse  of  alcohol. 

The  persistence  of  a  small  amount  of  milky  discharge, 
because  of  localization  of  inflammation  in  one  spot  or  the 
production  of  a  granular  patch  or  a  superficial  ulcer,  charac- 
terizes chronic  gonorrhea.  There  is  some  scalding  on  urina- 
tion ;  erections  produce  aching  pain  ;  there  are  pain  in  the 
back  and  redness  and  swelling  of  the  meatus.  All  the  symp- 
toms are  intensified  by  sexual  excitement,  by  coitus,  b}- 
violent  exercise,  or  by  alcoholic  excess. 

Gleet. — If  a  chronic  urethritis  lasts  over  ten  weeks,  it  is 
called  gleet.  In  gleet  the  lips  of  the  meatus  are  stuck  together 
in  the  morning,  and  squeezing  them  discloses  a  drop  of 
opalescent  mucopulent  fluid.  During  the  day  the  dis- 
charge is  rarely  found.  There  are  frequency  of  micturition, 
pains  in  the  back,  and  dribbling  of  urine,  and  a  bougie  will 
usually  find  a  stricture  of  large  caliber.  A  discharge  may  be 
maintained  b\-  clironic  prostatitis.  In  this  condition  there  are 
frequenc}'  of  micturition  ;  a  sense  of  weight  or  dull  pain  in 
the  perineum  ;  diminished  projectile  force  of  the  stream  of 
urine ;  there  is  often  a  tendency  to  sexual  excitement  and 
premature  emission.  In  chronic  anterior  urethritis  there  is 
a  discharge  from  the  meatus  or  sticking  together  of  the  lips 
in  the  morning.  In  chronic  posterior  urethritis  there  is  no 
discharge  of  pus  from  the  meatus.  If  two  beaker  glasses 
are  placed  upon  a  stand  and  the  patient  is  directed  to  urinate 
first  in  one  and  then  in  the  other,  if  he  suffer  from  chronic 
anterior  urethritis,  only  the  first  portion  will  be  cloudy  and 
show  shreds  ;  if  he  suffers  from   posterior  urethritis  of  not 

'  Schiitz's  method,  as  set  forth  by  R.  ^Y.  Taylor  in  his  work  upon  Venereal 
Diseases. 


I004         DISEASES   OE  GENITO-URINARY  ORGANS. 

very  long  standing,  both  portions  will  be  a  little  clouded, 
the  first  containing  clap  shreds,  the  second  hook-shaped 
shreds.  In  a  very  chronic  case  neither  sample  will  be 
cloudy,  but  the  first  portion  will  contain  shreds. 

Treatment  of  Acute  Gonorrhea. — Abortive  treatment 
may  be  tried  if  the  case  is  seen  early.  The  writer  formerly 
believed  that  by  cleansing  the  urethra  several  times  a  day 
with  peroxid  of  hydrogen,  following  the  hydrogen  by  the 
injection  of  oil  of  cinnamon  and  benzoinol,  many  cases  of 
gonorrhea  could  be  quickly  aborted.  Further  observations 
confirmed  by  bacterial  investigation  have  shown  that  he  was 
in  error.  True  gonorrhea  cannot  be  aborted  by  the  above- 
mentioned  plan.  Other  abortive  methods  are  the  use  of  hot 
retro-injections  of  corrosive-sublimate  solution  (i  :  20,000), 
two  pints  being  run  through  the  urethra  once  a  day ;  strong 
injections  of  nitrate  of  silver  or  of  tannin  ;  scraping  the 
meatus  or  the  urethra  adjacent  with  cotton,  and  injecting  15 
drops  of  a  3  per  cent,  solution  of  nitrate  of  silver.  If  in 
seventy-two  hours  the  symptoms  are  not  greatly  improved, 
abortive  treatment  should  be  abandoned.  Recent  studies 
render  it  almost  certain  that  there  is  no  real  abortive  treat- 
ment. Abortive  treatment,  to  be  efficient,  would  have  to  be 
carried  out  before  the  gonococci  penetrated  the  epithelial 
cells ;  in  other  words,  would  need  to  be  instituted  before  the 
symptoms  of  the  disease  appear.  Janet  says  that  we  must 
alter  our  conception  as  to  what  constitutes  abortive  treatment, 
and  he  doubts  if  a  case  of  true  gonorrhea  was  ever  really 
aborted.^  The  method  of  irrigation  with  solutions  of  perman- 
ganate of  potassium  is  really  a  prophylactic  treatment.  Janet 
applies  his  treatment  as  evidences  of  trouble  present  them- 
selves, and  before  acute  symptoms  appear,  and  claims  that 
in  most  persons  the  disease  can  be  arrested  in  from  eight  to 
twelve  days.  The  same  plan  of  treatment  is  useful  in  a  well- 
developed  case. 

Janet's  method  is  as  follows :  an  irrigator  is  filled  with  a 
warm  solution  of  permanganate  of  potassium  ( i  :  4000).  The 
patient  after  emptying  his  bladder  is  seated  upon  a  chair  and 
his  sacrum  rests  upon  the  extreme  front  edge  of  the  chair  (Val- 
entine). The  reservoir  is  joined  to  a  glass  nozzle  by  a  rubber 
tube.  The  nozzle  is  introduced  into  the  meatus,  and  the  fluid 
is  permitted  to  run  gradually  at  first,  with  full  force  later.  In 
anterior  trouble  the  fluid  is  allowed  to  run  out  of  the  meatus 
by  the  side  of  the  nozzle.  The  anterior  urethra  is  always 
irrigated  first,  the  reservoir  being  two  feet  above  the  chair. 

'  Ann.  d.  mal.  d.  org.  gen.-nrin.,  1896,  p.  I031. 


CUR  OXIC    L  'RE  THRA  L    DISCI  I  A  R  GES. 


1005 


In  posterior  urethritis,  after  the  anterior  urethra  has  been 
irrigated,  the  reservoir  is  raised  from  six  to  seven  feet  above 
the  bed,  the  meatus  is 
held  tight  about  the  noz- 
zle, and  the  fluid  over- 
comes the  force  of  the 
compressor  urethrs  mus- 
cles and  bladder  sphinc- 
ter and  enters  the  bladder. 
If  the  muscles  do  not 
quickly  relax,  continue 
the  hydrostatic  pressure 
for  several  minutes,  when 
relaxation  will  usually 
occur ;  but  if  it  does  not 
do  so,  tell  the  patient 
to  breathe  slowly  and 
deeply,  and  to  make 
efforts  at  urination  (Val- 
entine). When  the  blad- 
der is  full  the  tube  is 
withdrawn  and  the  pa- 
tient micturates.  This 
procedure  is  practised 
once  or  twice  a  day  for 
five  or  six  days,  or  even 
longer,  and  the  strength 
of  the  solution  is  grad- 
ually increased  up  to 
I  :  1000.  It  has  been 
claimed  that  after  one  or 
two  weeks  of  this  treat- 
ment gonococci  perma- 
nently disappear  in  the 
majority  of  cases.  Fig. 
393  shows  the  irrigator 
devised  by  Ferd.  C.  Val- 
entine. Valentine  of  New 
York  ^  has  constructed 
the  following  table,  which 

is  of  use  to  a  practitioner  who  wishes  to  employ  irrigations 
with  permanganate  of  potassium  in  the  treatment  of  acute 
gonorrhea : 

^  The  Irrigation  Treatment  of  Gonorrhea. 


Fig.  ^93. — Valentine's  urethral  and  intravesical 
irrigator  :  a,  board  with  attachments  to  be  screwed 
to  wall :  c.  open  collar ;  d.  pulley  ;  e,  cord  ;  /,  ring 
to  suspend  percolator ;  g,  brass  rod  ;  h,  percolator ; 
/,  rubber  tube  ;  j,  ring  for  fourth  finger  ;  k,  flange 
to  graduate  pressure  :  /,  shield  ;  in,  ring  to  suspend 
shield  ;  n,  nozzle  attached. 


ioo6 


DISEASES    OF   GENITO-UKINAK  V  ORGANS. 


First   Day,    first    visit.  Anterior  irrigation i  :  3000 

First    Day,  7  P.  M.  Anterior         "  i  :  4000 

Second  Day,  9  A.  M.  Anterior         "  i  :  3000 

Second  Day,  7  P.  M.  Anterior         "  i  :  4000 

Third  Day,  9  A.  M.  Intravesical  "  I  :  6000 

Third  Day,  7  P.  M.  Anterior         "  i  :  5000 

Fourth  Day,  9  A.  M.  Intravesical  "  i  :  5000 

t-       ^,    T-,  „  D    A/r    /  Intravesical  "  i  :  ?ooo 

fourth  Dav,     7  1.  M.  <    .    ,     .  ,,  ^ 

'       '  (  Anterior         "  I  :  2000 

Fifth  Day,  Noon.     Intravesical  "  i  :  5000 

Sixth  Day,  Noon.      Intravesical  " .  i  :  5000 

Seventh  Day,       Noon.     Intravesical  "  i  :  5000 

-c-  ,  ^1    r\  \    AT    f  Intravesical  "  i  :  i;ooo 

Eiehth  Day,     9  A.  M.  ^    ,    ,    •            ,,  -' 

°  ^^      y  ^  Anterior         "  I  :  3000 

T-  1-..1-  TN  »  Ti    -vT    )  IiUiavesical  "  i  :  i;ooo 

Eighth  Dav,      7  P.  M.  {    ^    ,    ■            ,.  ^ 

=>  -  >      /  ^  Anterior         "  .    ^ I  :  2000 

T.,.   ,,    T-.  A    AT    I  Intravesical  "  i  :  4000 

Ninth  Day,      9  A.  M.  -^  ^^^^^^.j^,.        .,         ^,  \^^^ 

,,.   ,,    T^  T.    Ar    (  Intravesical  " i  :  4000 

Ninth  Day,       7  F-  M.  ^  ^^^^^-^^^        „  ^.  \^^^ 

T,     ,,    -r^  A    A,r    I  Intravesical   "  I  :  4000 

Tenth  Day,      9  A.  M.  ^  ^^^^^^.j^^        .,         ^  ,^^^^ 

^      ,    ^  -n    A,r    I  Intravesical   "  I  :  qooo 

Tenth  Day,       1  ^■^^■Xs.nl.nox         "  1:500 

For  full  directions  regarding  this  method  see  Valentine's 
excellent  book,  TJic  Irrigation  Treatment  of  Gonorrhea. 
If  a  stricture  exists,  it  is  not  advisable  to  employ  this  treat- 
ment. Excellent  results  can  be  obtained  by  irrigations 
with  fluid  containing  silver  nitrate  (1:12,000  to  1:8000). 
In  treating  a  developed  ease,  order  plain,  non-stimulating  diet 
and  the  avoidance  of  alcohol,  sexual  excitement,  wet,  and 
violent  or  prolonged  exercise.  The  patient  should  sleep 
under  light  covers  and  drink  much  water  daily  (Seltzer, 
Apollinaris,  or  ordinary  water  containing  bicarbonate  of  so- 
dium). If  the  foreskin  is  long,  the  discharge  should  be  caught 
by  placing  bits  of  absorbent  cotton  ovei-  the  meatus  and  within 
the  prepuce.  If  the  foreskin  is  short,  cut  a  small  opening  in 
a  square  piece  of  old  linen,  slip  this  linen  over  the  glans, 
catch  it  back  of  the  corona,  and  bring  the  ends  forward  with 
the  prepuce.  If  the  glans  is  completely  naked,  pin  an  old 
stocking-foot  upon  the  undershirt  and  in  it  hang  the  penis. 
Order  a  man  to  wear  a  suspensory  bandage. 

Irritative  gonorrhea  will  subside  in  a  few  days.  The 
above  directions  should  be  followed,  and  the  anterior  urethra 
should  be  washed  out  several  times  daily  with  peroxid  of 
hydrogen,  or  irrigated  once  a  day  with  a  hot  solution  of  per- 
manganate of  potassium  ( i  :  4000).  In  catarrhal gono7-rhca,  at 
once  order  injections  (i  grain  to  the  ounce  of  sulphate  of  zinc; 
or  zinci  sulphas  gr.  viij,  plumbi  acetas  gr.  xv,  water  .^viij ;  or 
gr.  V  of  sulphocarbolate  of  zinc  to  3j  of  water ;  or  White's 


C//A'O.V/C    LRKIJIKAI.    DISCHARGES.  lOO/ 

prescription  of  sj  each  of  acetate  of  zinc  and  tannic  acid,  siij 
of  boric  acid,  5vj  of  liq.  hydrogen,  peroxid.).  For  injecting 
use  a  blunt-pointed  hard-rubber  syringe  of  a  capacit}'  of  three 
drams.  Let  the  patient  sit  on  a  chair,  his  buttocks  hanging 
over  the  edge  ;  throw  in  a  syringeful  and  let  it  at  once  run 
out;  throw  in  another  syringeful  and  hold  it  in  from  three  to 
five  minutes.  In  acute  gonorrhea  order  two  capsules  three 
times  a  day,  each  capsule  containing  5  grains  of  salol,  5  grains 
of  oleoresin  of  cubebs,  10  grains  of  balsam  of  copaiba,  and  i 
grain  of  pepsin.  After  the  patient  micturates  he  should 
employ  a  mild  astringent  injection.  If  an  astringent  injection 
causes  much  pain,  use  a  sedative  injection — sij  of  boric  acid, 
gr.  viij  of  aqueous  extract  of  opium,  and  sviij  of  liquor 
plumbi  subacetatis  dilutus.  As  the  inflammation  subsides 
increase  the  strength  of  the  injection.  A  good  plan  is  to 
order  an  eight-ounce  bottle  and  eight  half-grain  powders  of 
sulphate  of  zinc.  Direct  the  patient  to  fill  the  bottle  with 
water,  in  which  one  powder  is  dissolved ;  when  this  is  used 
dissolve  two  powders  in  a  bottleful  of  water,  and  so  pro- 
gressively increase  the  strength.  When  the  discharge  ceases 
stop  the  injections  gradually.  Whenever  a  syringeful  is 
taken  from  the  bottle  a  syringeful  of  water  is  put  into  the 
bottle,  and  thus  pure  water  is  soon  obtained,  at  which  point 
injection  is  discontinued. 

Argonin,  which  is  a  combination  of  albumin,  silver,  and 
an  alkali,  is  highly  recommended  by  some  authors  as  a  local 
remedy  for  gonorrhea  (Schaffer,  Guthiel).  A  solution  of 
this  material  is  non-irritant,  the  silver  is  not  precipitated  by 
chlorids,  and  the  agent  destroys  gonococci.  It  is  used  by 
injection  or  irrigation.  If  used  by  irrigation,  employ  a 
I  :  500  solution  twice  a  da}^  If  used  as  an  injection,  employ 
a  1  :  200  solution  six  or  eight  times  a  day.  When  the  dis- 
charge is  found  free  from  gonococci  and  remains  free  for 
three  days,  stop  the  argonin  and  use  an  astringent  injection. 

Protargol,  metallic  silver  combined  with  a  proteid,  is  a 
yellow  powder  soluble  in  water,  the  solution  not  being  acted 
on  by  light.  It  is  a  non-irritant  germicide.  Neisser,  after 
demonstrating  the  presence  of  the  gonococcus,  administers 
protargol  by  injection,  the  first  injections  being  of  a  strength 
of  0.25  per  cent.,  the  strength  being  gradualh'  increased  to 
0.5  per  cent.,  and  finally  to  i  per  cent.  In  the  beginning 
he  orders  three  injections  a  day,  each  injection  being  retained 
from  fifteen  to  thirty  minutes  ;  after  several  da}^s  when  the 
symptoms  improve  he  gives  only  one  or  two  injections  a 
day,  and  these  are  continued  for  ten  days  after  gonococci 


I008         DISEASES    OF   GENITO- URINARY  ORGANS. 

disappear  from  the  discharge.  After  protargol  is  abandoned 
an  astringent  injection  should  be  used  for  a  time.  Some 
surgeons  use  a  i  :  looo,  solution  of  protargol,  and  irrigate 
the  anterior  urethra  and  flush  the  bladder  twice  a  day. 

Methylene-blue  internally  is  occasionally  of  service  in 
gonorrhea.  A  capsule  containing  gr.  ij  of  the  drug  is  given 
three  times  a  day.  It  makes  the  urine  greenish-blue  and 
occasionally  induces  strangury. 

Ardor  iirincB  is  relieved  by  urinating  while  the  penis  is 
immersed  in  hot  water  and  by  administering  an  alkaline  diu- 
retic. CJiordee  requires  a  bowel-movement  in  the  evening, 
and  sleeping  in  a  cool  room,  under  light  covers,  and  on  a  hard 
mattress ;  bromid  is  given  several  times  daily,  and  a  con- 
siderable dose  is  given  at  night ;  it  may  be  necessary  to  use 
suppositories  of  opium  and  camphor  or  to  give  hyoscin. 
Balanitis  requires  frequent  washing  with  warm  water,  drying 
with  cotton,  and  dusting  with  borated  talc  or  with  boric  acid 
and  subnitrate  of  bismuth  (i:6).  Balanoposthitis 'i-Qquirts 
soaking  in  hot  water,  applications  of  lead-water  and  laud- 
anum, and  injections  of  black  wash  under  the  prepuce  until 
edema  of  the  foreskin  subsides,  and  then  cleanliness  and  the 
application  of  a  drying  powder.  Phimosis  requires  soaking 
the  penis  in  hot  water,  injections  of  hot  water  beneath  the 
foreskin,  followed  by  black  wash,  and  the  use  of  lead-water 
and  laudanum  externally.  If  this  fails,  circumcision  must 
be  performed.  If  paraphimosis  occurs,  grasp  the  head  of 
the  penis  with  the  left  hand,  squeeze  the  blood  out,  and  try 
to  push  the  head  back  while  with  the  right  hand  the  penis 
is  pulled  upon,  as  if  the  surgeon  intended  to  lift  the  indi- 
vidual by  the  organ.  If  this  fails,  cut  the  collar  on  the 
dorsum  with  scissors.  Bubo  requires  the  application  of 
iodin,  ichthyol,  or  blue  ointment,  the  use  of  a  spica  bandage, 
and  rest.  If  a  bubo  suppurates,  it  must  be  opened  or  aspi- 
rated. Acute  prostatitis  and  cystitis  require  confinement  to 
bed,  a  milk-diet,  the  use  of  alkaline  diuretics,  hot  applications 
to  the  perineum  and  hypogastrium,  suppositories  of  opium 
and  belladonna  or  ichthyol,  leeching  the  perineum,  and  the 
discontinuance  of  the  balsams  and  injections.  Abscess  of  the 
prostate  requires  instant  incision.  In  retention  of  nrine  the 
patient  should  try  to  pass  the  urine  while  in  a  hot  bath  ; 
if  this  fails,  a  soft  catheter  is  used.  After  relieving  the  blad- 
der put  the  patient  to  bed  and  apply  hot  sand-bags  as  for 
acute  prostatitis.  Chronic  prostatitis  requires  cold  hip-baths, 
cold-water  enemata,  deep  urethral  injections,  plain  diet,  avoid- 
ance of  alcohol   and  over-exertion,  counter-irritation  of  the 


CHRONIC   UKETHRAL   DISCHARGES.  IOO9 

perineum,  and  the  relief  of  stricture  or  phimosis.  Great 
benefit  is  occasionally  derived  from  passing  a  soft  bougie 
covered  with  blue  ointment.  If  epididymitis  arises,  put  the 
patient  to  bed,  abandon  injections,  shave  the  hair  from 
the  groin,  leech  over  the  cord,  elevate  the  testicles,  and 
apply  an  'ice-bag.  Give  a  cathartic,  a  fever  mixture,  and 
suitable  doses  of  bromid  of  potassium  and  morphin.  The 
application  twice  a  day  of  20  drops  of  guaiacol  in  .^j  of  cos- 
molin  or  olive  oil  gives  great  relief.  When  swelling  lingers, 
after  tenderness  subsides  strap  the  testicle  with  adhesive 
plaster.  A  lingering  case  is  benefited  by  the  internal  use 
of  iodid  of  potassium  and  the  local  application  of  ichthyol. 
In  gonorrheal  oplitJudmia  secure  a  watch-crystal  over  the 
unaffected  eye,  put  the  patient  in  a  darkened  room,  rub 
the  infected  conjunctival  sac  with  cotton  soaked  in  a  2  per 
cent,  solution  of  silver  nitrate,  wash  out  the  affected  eye 
often  with  hot  boric-acid  solution,  keep  the  pupil  dilated 
with  atropin,  leech  the  temple,  give  purgatives,  and  employ 
hot  mustard  foot-baths.     Always  send  for  an  ophthalmolo- 

Treatment  of  Chronic  Urethral  Discharges. — Gradually 
dilate  the  urethra  with  metal  sounds.  In  chronic  gonorrhea 
try  to  locate  any  existing  granular  or  ulcerated  patch  with  a 
bulbous  bougie.  When  the  point  is  discovered  apply  to  it,  by 
a  deep  urethral  syringe,  a  few  drops  of  a  2  per  cent,  solution 
of  nitrate  of  silver.  The  strength  of  the  silver  solution  can 
gradually  be  increased,  or  other  solutions  can  be  substituted 
(sulphate  of  copper  or  sulphocarbolate  of  zinc).  Pass  a  large 
bougie  every  other  day.  Copious  retro-irrigation  with  hot 
solutions  of  corrosive  sublimate  (i  :  20,000),  permanganate  of 
potassium  (i  :  3000),  or  nitrate  of  silver  (i  :  8000)  does  good. 
In  many  cases  an  electric  endoscope  is  an  indispensable 
instrument.  By  means  of  it  the  surgeon  is  enabled  to  locate 
the  trouble  and  treat  it  locally.  A  common  cause  of  chron- 
icity  is  lingering  inflammation  of  glandular  structures  and 
lacunse.  These  spots  should  be  touched  through  an  endo- 
scope tube,  from  time  to  time,  with  silver  nitrate  (3  per  cent.). 
A  granular  patch  should  be  treated  in  the  same  manner.  In 
any  lingering  case  of  gonorrhea  examine  the  urine,  and  direct 
suitable  treatment  for  oxaluria,  lithemia,  or  phosphaturia, 
if  any  one  of  these  conditions  exist.  Such  morbid  states  of 
the  urine  are  occasionally  responsible  for  great  prolongation 
of  the  inflammation.  In  some  cases  a  discharge  is  kept  up 
by  inflammation  of  the  seminal  vesicles  (p.  1023).  When 
may  a    man    be   considered    well  of  gonococcus    infection? 

64 


lOIO        DISEASES   OF  GENITO-URINARY  ORGANS. 

When  shreds  disappear  from  the  urine  ;  when  an  examina- 
tion on  three  successive  days  fails  to  find  gonococci;  when 
the  urine  is  free  from  pus,  and  when  there  has  been  no  dis- 
charge for  ten  days. 

Gonorrhea  of  the  rectum  occasionally,  though  very 
rarely,  occurs.  It  may  result  from  pederasty,  or  in  a  woman 
from  a  flow  of  infectious  material  from  the  genitalia  to  the 
anus. 

Gonorrhea  in  the  female  may  affect  the  vulva,  the 
vagina,  the  urethra,  or  the  uterus.  The  danger  is  the  devel- 
opment  of  metritis  or  salpingitis. 

The  treatment  for  vulvitis  is  to.  place  the  patient  upon  a 
low  diet  and, put  her  at  rest  with  the  pelvis  elevated;  ever^' 
two  or  three  hours  spray  the  parts  with  peroxid  of  hydrogen, 
dry  them  with  absorbent  cotton,  and  dust  them  with  equal 
parts  of  starch  and  oxid  of  zinc.  In  severe  cases  purge,  use 
hot  baths,  apply  lead- water  and  laudanum  locally  or  paint 
the  vulva  with  silver  solution  (gr.  xl  to  5J),  and  leech  the 
groins.     If  the  vulvovaginal  gland  suppurates,  open  it. 

For  vaginitis  follow  the  same  general  directions.  Wash 
out  the  vagina  every  two  hours,  first  with  Oj  of  hot  solution 
of  bicarbonate  of  sodium,  next  with  Oj  of  hot  water,  and 
finally  with  Oj  of  astringent  solution  (a  teaspoonful  of  lead 
acetate,  a  teaspoonful  of  zinc  sulphate,  a  teaspoonful  of  alum, 
or  four  teaspoonfuls  of  tannin  to  the  pint  of  hot  water) 
(White).  As  the  attack  subsides,  use  vaginal  suppositories, 
each  containing  gr.  v  of  tannic  acid.  In  some  cases  apply 
solutions  of  silver  nitrate,  i  :  200,  and  insert  tampons  moist- 
ened with  boroglycerid  and  ichthyol,  8  per  cent.  (Le  Blonde). 
Metritis  must  be  prevented,  and  it  is  a  wise  precaution  to 
apply  iodin  from  time  to  time. 

For  urctliritis  use  astringent  injections  locally  and  copaiba 
and  cubebs  by  the  mouth.  In  chronic  cases  use  strong 
solutions  of  silver  nitrate.  The  urethra  and  bladder  may  be 
irrigated  with  silver  nitrate  (i  :  8000). 

Y ox  uterine  gonorrliea  observe  the  same  general  manage- 
ment. Swab  out  the  uterus  with  tincture  of  iodin ;  use 
tampons  of  iodoform  gauze  and  injections  of  peroxid  of 
hydrogen. 

Stricture  of  the  urethra,  or  narrowing  of  the  urethral 
caliber,  is  divided  into  inflammatory,  spasmodic,  and  organic. 
The  so-called  inflammatory  or  congestive  stricture  is  not  a 
stricture,  but  is  an  inflammatory  swelling  of  the  mucous 
membrane. 

Spasmodic  stricture  does  not  exist  alone,  but  complicates 


STJ^ICTC'RE    OF   THE    CRRTIIKA.  10 1  I 

organic  stricture,  a  hypcresthetic  urethra,  or  an  inflamed 
bladder. 

Organic  stricture  is  a  fibrous  narrowing  of  the  urethra, 
due,  as  a  rule,  to  chronic  gonorrheal  inflammation  or  to 
traumatism.  Traumatic  strictures  occur  in  the  bulbous  or 
membranous  urethra,  and  are  due  generally  to  force  applied 
to  the  perineum,  the  urethra  being  squeezed  between  the 
subpubic  ligament  and  the  vulnerating  body.  Strictures 
resulting  from  gonorrheal  inflammation  occur  in  the  penile, 
bulbous,  or  membranous  urethra.  Stricture  never  forms  in 
the  prostatic  urethra  except  as  a  result  of  traumatism. 
Recent  non-traumatic  strictures  are  soft  and  are  easily  dis- 
tended. Old  strictures  and  traumatic  strictures  are  very 
dense.  A  resilient  stricture  is  one  which  contracts  quickly 
after  dilatation.  The  nearer  a  stricture  is  to  the  meatus, 
the  more  fibrous  it  is. 

A  congenital  stricture  is  congenital  narrowness  of  a  por- 
tion_  of  the  urethra,  usually  the  portion  near  the  meatus. 
The  more  fibrous  a  stricture  is,  the  more  it  narrows  the 
urethra  and  the  less  dilatable  it  is.  A  stricture  may  be 
annular^ (forming  a  ring  around  the  urethra),  tubular -(sur- 
rounding the  urethra  for  a  considerable  distance),  or  bridle 
(when_aJaaad_(:rosses  the  urethra  from  wall  to  wall).  A 
stricture  of  large  caliber  will  admit  an  instrument  larger 
than  a  No.  1 5  French  sound.  A  stricture  of  small  caliber 
will  not  admit  a  No.  15  French  sound.  An  impermeable 
stricture  will  not  admit  the  passage  of  any  instrument. 
Impermeable  is  more  or  less  a  relative  term.  A  stricture 
may  be  impermeable  when  an  anesthetic  is  not  used,  and 
permeable  when  the  patient  is  anesthetized,  or  may  be  im- 
permeable to  one  surgeon,  but  permeable  to  another.  Im- 
permeabilit)-  is^often  a  temporar\'  condition  due  to  inflam- 
mator}'  edema  about  an  organic  stricture. 

Symptoms  and  Results  of  Stricture. — There  is  usually 
a. history  of  repeated  attacks  of  urethritis.  A  chronic  dis- 
charge may  exist,  the  amount  of  which  is  variable.  There 
is  a  feeling  of  weight  in  the  perineum,  soreness  of  the 
back,  and  frequency  of  micturition.  Hypochondriacal  ten- 
dencies are  usual.  There  is  difficulty  in  starting  the  stream 
in  micturition  ;'  the  stream  is  small,  twisted,  often  forked,  and 
it  dribbles  long  after  the  conclusion  of  the  act,  so  that  the 
penis  must  be  "  milked "  before  it  is  returned  within  the 
clothing.  The  urethra  back  of  the  stricture  dilates,  a  pouch 
forms,  drops  of  urine  collect  and  decompose,  and  a  chronic 
inflammation  results  in  the  mucous  membrane  or  the  parts 


IOI2         DISEASES    OE   GENErO-URINARY  ORGANS. 

adiacent,  which  inflammation  may  go  on  to  ulceration  or  to 
peri-urethral  abscess.  A  urinary  fistula  results  from  the 
opening  externally  of  a  peri-urethral  abscess.  Retention 
of, urine  may  occur,  not  from  obliteration  of  the  tube  by 
the  growth  of  the  stricture,  but  closure  of  its  lumen  by  ede- 
matous swelling  in  the  neighborhood  of  the  stricture,  due 
to  cold,  wet,  venereal  excitement,  the  use  of  alcohol,  over- 
exertion, etc.  Spasm  of  the  muscles  results,  and  contact  of 
the  urine  increases  the  spasm,  and  spasm  plus  edema  oi  the 
mucous  membrane  closes  the  urethra.  Spasm  may  exist  in 
the  urethra  itself^and._in- the  .muscles  of  the  neck  of  the  blad- 
der7b'uFis  only  a  temporaiy  condition.  In  old  strirtures 
the  bladder  is  hypertrophied  and  often  fasciculated,  and  is 
very  liable  to  cystitis.  The  diagnosis  of  stricture  and  of  its 
location  is  made  by  the  use  of  exploratory  bougies.  In  this 
examination  the  author  follows  to  a  great  extent  the  plan  of 
Ramon  Guiteras,  which  is  as  follows  :  ^  have  the  patient  pass 
urine  into  two  glasses.  Examine  the  urine  for  clap-shreds. 
Cloudiness  in  the  first  glass  shows  that  urethral  discharge 
exists.  Cloudiness  in  the  second  glass  points  to  cystitis. 
The  patient  is  placed  recumbent  with  his  shoulders  elevated, 
and  the  urethra  is  washed  out  with  warm  salt  solution. 
Bulbous  sounds  are  inserted,  beginning  with  No.  1 5  French. 
If  this  passes  with  ease,  take  a  larger  size  and  note  where 
strictures  are  situated  by  the  catch  on  withdrawal.  If  No. 
15  does  not  pass,  use  a  smaller  size.  Remember  that  the 
posterior  layer  of  the  triangular  ligament  catches  a  bulbous 
instrument  on  withdrawal.  If  the  meatus  is  too  small  to 
permit  of  exploration,  divide  it  with  a  curved  bistoury,  cutting 
from  within  outward.  After  cutting  the  meatus  bleeding  is 
arrested  with  styptic  cotton,  and  a  piece  of  absorbent  cotton 
is  tucked  into  the  cut.  After  each  act  of  micturition  the 
patient  inserts  a  fresh  bit  of  cotton,  and  after  three  days  the 
urethral  examination  is  proceeded  with. 

Treatment. — A  stricture  of  large  caliber  in  the  deep  ure- 
thra requires  gradual  dilatation.  A  steel  bougie  is  intro- 
duced every  fifth  day,  the  size  being  gradually  increased. 
Never  anoint  a  bougie  with  cosmolin,  as  it  may  become  a 
nucleus  for  a  stone  in  the  bladder ;  use  oil  or  glycerin 
or  lubrichondrin.  Before  passing  an  instrument  the  patient 
urinates  and  his  urethra  is  washed  out  with  boiled  water 
or  salt  solution.  The  sound  is  rendered  sterile  by  boiling 
before  using.  Gradual  dilatation  can  be  effected  by  the 
use  of  the  dilator  of  Oberlander,  the  tube  being  distended 

1  Med.  Record,  Nov.  14,  1896. 


STRICTURE    OF   THE    URETHRA.  IOI3 

to  the  extent  of  three  millimeters  every  fifth  day.  If  after 
dilatation  there  is  urethral  spasm,  pain,  or  very  frequent 
micturition,  suspend  the  treatment  for  a  number  of  days 
and  order  each  night  a  hot  hip-bath  and  a  dose  of  pare- 
goric. In  effecting  gradual  dilatation  by  sounds  the  instru- 
ment should  be  introduced  every  fifth  day,  and  during 
the  treatment  the  patient  should  not  use  alcohol,  should 
refrain  from  sexual  excitement,  should  avoid  cold  and  damp, 
and  should  take  internally  capsules  containing  boric  acid  and 
salol. ..  It  is  rarely  necessar}^  to  dilate  above  No.  32  French. 
After  the  surgeon  finishes  treatment  he  teaches  the  patient 
to  use  an  instrument  and  directs  him  to  pass  it  once  a  month. 
Strictures  in  .the  pendulous  urethra,  if  soft,  are  treated  by 
gradual  .dilatation ;  if  fibrous  and  contractile,  by  internal 
^urethrotomy.  Iji  performing  internal  urethrotom}'  prepare 
the  patient  carefulh-;  for  several  days  before  the  operation 
give  salol  and  boric  acid  b}^  the  mouth,  and  wash  out  the 
bladder  repeatedly  with  boric -acid  solution.  Be  thoroughly 
aseptic.  Anesthetize  the  patient.  Before  cutting  irrigate  the 
urethra  with  warm  normal  salt  solution,  and  after  cutting 
irrigate  again  and  tie  in  a  rubber  catheter.  These  precau- 
tions will  prevent  urethral  fever.  In  cutting,  insert  Gross's 
urethrotome  (Fig.  397)  back  of  the  stricture,  spring  out  the 
blade,  cut  the  stricture  on  the  roof  of  the  urethra,  close  the 
blade,  withdraw  the  instrument,  and  pass  a  full-sized  bougie. 
Stricture  of  the  meatus  requires  incision  with  a  knife  and 
the  use  of  a  meatus  bougie  until  healing  is  complete.  Strict- 
ures  of  small  caliber  in  front  of  the  membranous  urethra 
require  gradual  dilatation  -and,  if  this  fails,  internal  urethrot- 
omy or  divulsion.  Internal  urethrotomy  can  be  performed 
with  the  urethrotome  of  Maisonneuve  (Fig.  395).  This 
instrument  is  shaped  like  a  sound,  has  a  groove  upon  its 
surface,  and  into  this  groove  a  shaft  carrying  a  triangular 
knife  can  be  inserted.  The  staff  is  screwed  to  a  guide,  the 
guide  is  carried  into  the  bladder  and  the  staff  follows  it. 
The  point  of  the  staff  is  carried  to  the  prostatic  urethra  and 
the  guide  curls  up  in  the  bladder.  The  penis  is  held  upon 
the  stretch,  the  blade  is  inserted  and  pushed  down  through 
the  stricture.  This  instrument  cuts  the  stricture,  but  not 
the  health}-  urethra.  For  divulsion  the  patient  is  prepared  as 
for  internal  urethrotom}-.  The  divulsor  of  Gross,  or  of  Sir 
Henry  Thompson,  or  of  Gouley  (Figs.  396,  398,  399)  is 
introduced,  the  blades  are  separated,  the  instrument  is 
withdrawn,  a  large  bougie  is  passed,  and  a  catheter  is  tied 
in  the  bladder.     Strictures  of  small  caliber  in  the  deep  ure- 


10I4         DISEASES    OF  GENITO-CRINARY  ORGANS. 

thra  require  gradual  dilatation ;  if  this  fails,  employ  external 
urethrotomy.  In  strictures  of  the  deep  urethra,  if  only  a  fili- 
form bougie  can  be  introduced,  the  bougie  may  be  left  in  place. 


Fig.  394. — Syme's  staff. 


Fig.  395. — Maisonneuve's  urethrotome. 


and  in  a  day  or  two  another  can  be  slipped  in  beside  it,  until  in 
a  few  days  the  channel  is  permeable  by  a  metal  bougie.  A 
tunnelled  catheter  can  be  slipped  over  the  filiform  bougie, 


STRICTURE    OF   THE    URETHRA. 


IOI5 


both  be  withdrawn,  and  a  metal  bougie  passed.  A  tun- 
nelled and  grooved  staff  can  be  carried  in  over  the  bougie 
and  external  urethrotomy  be  performed.  Thompson's  dilator 
can  be  carried  in  over    the    filiform    and    the    stricture    be 


Fig.  396. — Gross's  urethral  dilator. 


Fig.  397. — S.  W.  Gross's  explora- 
tory urethrotome. 


divulsed.  Fort's  method  of  electrolysis  is  said  to  be  of 
value,  but  I  have  had  no  personal  experience  with  it.  Fort 
treats  stricture  by  linear  electrolysis.  His  instrument  looks 
like  a  whip,  and  it  has  a  platinum  blade  projecting  from 
about  the  center.     The  blade  is  connected  with  the  negative 


ioi6 


DISEASES   OF  GENITO- URINARY  ORGANS. 


pole  of  a  galvanic  battery  and  the  positive  pole  is  placed 
over  the  pubes.  The  guide  carrying  the  blade  is  inserted 
into  the  urethra,  and  when  the  blade  comes  against  the 
stricture  the  current  is  turned  on  and  the  platinum  passes 
rapidly  through  the  constriction.  The  current  is  turned  off 
and  the  instrument  is  carried  onward  until  it  strikes  another 
stricture,  when  the  current  is  again  turned  on,  and  so  on. 
The  necessary  current-strength  is  lo  to  15  ma.  The  op- 
eration   requires    twenty  to  thirty  seconds  and    causes  but 


Fig.  398. — Thompson's  divulsor. 

little  pain.  After  its  performance  a  sound  is  passed  (a  No. 
22  of  the  French  scale).  The  patient  need  not  be  confined 
to  bed  after  this  operation.  By  Fort's  method  Ave  act 
purely  upon  the  diseased  tissue.  In  impassable  stricture 
of  the  deep  urethra  perform  external  perineal  urethrotomy 
without  a  guide  (the  operation  of  Wheelhouse). 

If  a  perineal  fistula  exists,  dilate,  divulse,  or  cut  the 
stricture,  retain  a  catheter  in  the  bladder  for  forty-eight 
hours.     After  this  period  dilate  every  few  days  with  a  metal 


Fig.  399. — Gouley's  divulsor. 

instrument.  Every  morning  and  evening  draw  the  urine 
with  a  soft  catheter,  introduce  boric-acid  solution  into  the 
bladder,  remove  the  catheter,  and  let  the  man  empty  his 
bladder  naturally.  A  portion  will  flow  from  the  fistula  and 
a  part  from  the  meatus.  Day  by  day  the  quantity  which 
comes  from  the  fistula  lessens,  and  finally  the  abnormal 
opening  heals. 

Urethral  Fever. — Any  operatien-upon  the  urethra  may 
be  followed  by  a  chill  owing  to  shock  (urethral  shock),  and 
this  may  be  followed  by  a  nervous    fever.     Urethral    fever 


UKIXAKV  FEVER.  lOI/ 

proper  is  a  sapremia  which  may  follow  a  urethral  opera- 
tion. This  condition  is  due  to  absorption  of  toxic  elements 
\vFicFmay  be  in  the  uriiie,  may  have  been  in  the  urethra,  or 
ma\'  have  been  introduced  from  without.  It  usually  follows 
the'  first  urinary  act  after  operation.  It  begins  with  a  violent 
chill  and  presents  the  characteristics  of  a  septic  fever.  It  is 
accompanied  by  a  marked  tendency  to  urinary  suppression, 
and  may  eventuate  in  septicemia  or  pyemia.  Urethral  fever 
can  be  prevented  by  rigid  antisepsis.  If  this  fever  should 
arise,  a  catheter  must  be  tied  in  the  bladder,  the  bladder  and 
urethra  must  be  repeatedly  irrigated  with  aseptic,  or  anti- 
septic fluids,  and  the  patient  must  be  given  urinary  antiseptics 
and  stimulants  by  the  mouth. 

Urinary  Fever. — Sir  Benjamin  Brodie  pointed  out  that 
the  withdrawal  of  residual  urine  in  a  case  of  enlarged 
prostate  may  be  followed  by  very  serious  symptoms.  The 
condition  is  spoken  of  as  urinary  fever,  and  is  said  by  many 
to  be  due  to  the  sudden  and  complete  emptying  of  a  bladder 
which  has  become  accustomed  to  retaining  permanently  a 
considerable  quantity  of  urine. 

The  condition  does  not  arise  promptly,  suddenly,  and 
violently,  as  does  urethral  fever,  but  begins  rather  insidiously 
after  several  days.  Mr.  C.  Mansell  MouUin  thus  describes 
the  condition :  ^ 

"  So  far  as  the  broader  features  are  concerned,  the  symp- 
toms that  present  themselves  in  these  cases  are  remarkably 
uniform.  They  do  not  begin  at  once.  Nearly  always 
some  few  day's  elapse  before  there  is  anything  to  excite 
suspicion.  Then  the  urine  becomes  cloudy,  though  it  may 
still  retain  its  acid  reaction.  A  small  quantity  of  albumin, 
more  than  can  be  accounted  for  by  the  amount  of  pus  that 
is  present,  makes  its  appearance.  Under  the  microscope 
there  arc  a  few  hyaline  casts,  perhaps  a  blood-corpuscle  or 
two,  numerous  pus-corpuscles,  and  myriads  of  bacteria. 
The  specific  gravity  is  lower  than  it  ought  to  be,  and  is 
lower  than  it  was  before  the  catheter  was  used.  The 
total  amount  passed  in  the  twenty-four  hours  may  either 
increase  until  it  is  as  much  as  seven  or  eight  pints,  or 
diminish  until  it  scarcely  reaches  twenty  ounces.  There 
is  seldom  any  definite  rigor,  but  there  may  be  numerous 
slight  chills. '  The  pulse  grows  more  rapid  and  feeble. 
The  tongue  becomes  red  and  dry.  There  is  complete 
anorexia.'  Delirium  sets  in  at  night,  and  in  a  consider- 
able proportion  of  cases  the  symptoms  rapidly  grow  worse 

"^Lancet,  September  lo,  1898. 


I0l8         DISEASES    OF   GENITO-URINARY   ORGANS. 

and  worse  until,  at  the  end  of  a  few  days,  the  patient  sinks 
into  a  semi-comatose  condition  from  which  he  seldom  rallies. 
Post-mortem  there  are  all  the  signs  of  recent  acute  cystitis 
and  pyelonephritis.  The  mucous  membrane  lining  the 
pelvis  and  calices  of  the  kidneys,  the  ureters,  and  the  bladder 
is  swollen  and  stained  by  old  and  recent  hemorrhages,  and 
here  and  there  a  thin  layer  of  pus  is  adherent  to  it.  The 
pelvis  and  the  ureters  are  dilated,  the  apices  of  the  pyramids 
are  eaten  away,  the  cortex  is  shrunken  and  hard,  the  capsule 
is  adherent,  and  in  places  between  the  tubules  are  minute 
collections  of  pus  differing  in  shape  and  outline  according  to 
the  anatomical  arrangement." 

Modern  studies  prove  that  urinary  fever  is  due  to  infection 
of  the  bladder  and  kidneys,  and  not  simply  to  the  sudden 
withdrawal  of  all  of  the  urine  from  the  bladder,  although 
such  a  procedure  leads  to  vesical  congestion  and  probably 
favors  infection.  The  organisms  most  often  found  are 
pyogenic  cocci,  colon  bacilli,  and  organisms  which  cause 
putrefaction  and  decomposition  of  urea. 

Treatment. — Aseptic  catheterization  is  necessary  if  we 
would  avoid  urinary  fever;  and  as  the  urethra  contains  some 
of  the  causative  organisms,  the  prepuce,  glans,  and  meatus 
should  be  washed  with  soap  and  water  and  irrigated  with 
boric-acid  or  permanganate  of  potassium  solution,  and  the 
urethra  be  irrigated  with  boric-acid  solution  or  permanganate 
of  potassium  before  the  sterile  catheter  is  introduced  to 
draw  the  urine. 

If  urinary  fever  arises,  it  may  be  possible  to  control  it  by 
frequently  irrigating  the  bladder  with  warm  normal  salt  solu- 
tion, solution  of  nitrate  of  silver  (i  :  8000),  or  boric-acid  solu- 
tion, and  by  administering  stimulants,  diuretics,  diaphoretics, 
saline  cathartics,  and  nutritious  food.  In  severe  cases  per- 
form suprapubic  cystotomy  for  drainage. 

Perineal  section  is  external  perineal  urethrotomy.  There 
are  three  methods,  the  operation  of  Syme,  of  Wheelhouse, 
and  of  Cock. 

Syme's  Operation. — This  operation  is  employed  if  a 
stricture  is  very  contractile,  if  dilatation  fails  to  cure,  or  if 
urethral  instrumentation  causes  fever.  The  patient  is  anes- 
thetized, Syme's  staff  (Fig.  394)  is  introduced,  and  the  sur- 
geon makes  an  incision  in  the  midline  of  the  perineum  and 
exposes  the  staff  just  above  the  shoulder  of  the  instrument. 
The  knife  is  carried  along  the  groove  and  divides  the  strict- 
ure. A  catheter  is  passed  into  the  bladder  from  the  meatus 
and  is  retained  for  several  days,  and  the  wound  is  dressed 


HYPO  SPA  DIA  S.  1019 

antisepticall}'.  After  the  catheter  is  removed  it  must  be 
used  every  six  hours  until  the  urine  comes  entirely  by  the 
meatus.  From  time  to  time,  for  the  rest  of  the  patient's 
life,  a  full-sized  sound  should  be  passed. 

Wheelhouse's  Operation. — This  operation  is  employed 
for  the  treatment  of  impermeable  stricture.  Wheelhouse's 
staff  is  passed  into  the  urethra  until  it  blocks  on  the  stricture. 
The  perineum  is  incised  down  to  the  staff  and  in  front  of  the 
stricture.  The  edges  of  the  cut  urethra  are  held  apart  with 
forceps,  the  surgeon  seeks  for  the  opening  through  the  strict- 
ure, passes  a  fine  probe  through  it,  divides  the  stricture,  carries 
into  the  bladder  from  the  wound  an  instrument  knowm  as  a 
gorget  to  dilate  the  canal  and  furnish  a  solid  floor  to  facilitate 
the  introduction  of  a  catheter.  With  the  gorget  in  place  a 
metal  catheter  is  carried  from  the  meatus  into  the  bladder. 
The  gorget  is  removed  and  the  catheter  is  tied  in  place. 
After  three  or  four  days  the  catheter  is  removed  and  is  then 
passed  frequently.  The  perineal  wound  is,  of  course,  dressed 
antiseptically. 

Cock's  Operation. — This  operation  opens  the  urethra 
back  of  the  stricture  and  without  a  guide  relieves  retention 
of  urine.  The  surgeon  introduces  into  the  rectum  the 
index-finger  of  the  left  hand,  and  the  tip  of  the  finger  is 
rested  upon  the  apex  of  the  prostate  gland.  The  surgeon 
incises  the  median  line  of  the  perineum,  the  back  of  the 
knife  being  toward  the  anus.  When  the  point  of  the  knife 
is  felt  to  be  near  the  finger  the  handle  is  lowered  slightly, 
the  blade  is  placed  a  little  oblique,  and  the  urethra  is  opened. 
A  catheter  is  passed  into  the  bladder  from  the  wound  and 
retained  for  a  time,  and  the  stricture  is  subsequently  treated. 

l^pispadias  is  a  congenital  cleft  in  the  corpora  cavernosa, 
the  roof  of  the  urethra  being  completely  or  partly  absent. 
In  complete  epispadias  there  are  absence  of  the  pubic  arch 
and  exstrophy  of  the  bladder. 

Partial  epispadias  may  sometimes  be  remedied  by  a  plastic 
operation. 

Hypospadias  is  a  congenital  cleft  on  the  floor  of  the 
urethra,  the  meatus  opening  on  the  floor  at  some  point  be- 
tween the  scrotum  and  the  end  of  the  glans  penis,  the  chan- 
nel in  front  of  the  meatus  being  a  gutter  and  not  a  tube. 

Hypospadias  of  the  glans  is  the  most  common  form.  In 
this  condition  the  urethra  has  no  floor,  as  it  passes  beneath  the 
glans,  the  site  of  the  urethra  is  indicated  by  a  groove,  and 
the  foreskin  is  absent  below.  Partial  hypospadias  requires  no 
treatment  except  possibly  dilatation  or  incision  of  the  meatus. 


1020         DISEASES    OF   GENITO-URINARY  ORGANS. 

People  who  suffer  from  it  are  very  prone  to  develop  chronic 
urethral  inflammation.  In  hypospadias  of  the  penis  the  ill- 
developed  cord-like  corpus  spongiosum  draws  the  penis  to 
the  scrotum.  In  this  variety  of  the  deformity  the  penis  is 
very  short. 

In  complete  hypospadias  the  opening  of  the  urethra  is 
back  of  the  scrotum  in  the  perineum,  the  penis  is  dwarfed 
and  bound  down,  and  looks  not  unlike  a  clitoris,  the  scrotum 
is  divided  into  two  portions,  a  gap  existing  between  them, 
and  in  many  cases  the  testicles  have  not  descended.  Such 
individuals  are  occasionally  mistaken  for  females.  In  the 
penile  complete  forms  of  hypospadias  a  plastic  operation 
should  be  performed  between  the  eighth  and  tenth  year  of 
age.  Such  an  operation  unfortunately  may  fail.  Hypo- 
spadias is  rare  in  women,  but  it  may  occur.  In  such  a  case 
the  urethra  opens  into  the  vagina. 

Chancroid  (soft  chancre  ;  the  local  venereal  sore)  is  a 
pyogenic  ulcer,  usually  of  venereal  origin.  The  name 
chancroid  was  introduced  by  Clerc,  who  believed  that  a  soft 
sore  resulted  from  inoculating  a  person  already  syphilitic 
with  the  products  of  a  hard  sore.  He  further  held  that  when 
a  soft  sore  arose  the  syphilitic  poison  lost  its  infective  prop- 
erties, and  "  could  be  transmitted  as  a  soft  sore  to  a  healthy 
person,  and  not  cause  general  infection."  ^  This  form  of  ulcer 
is  not  connected  with  the  syphilitic  poison  and  is  not  due  to 
any  special  or  chancroidal  poison,  but  is  produced  by  inflam- 
matory products  or  irritating  secretions.  In  fact,  soft  sores 
may  arise  without  a  causative  sexual  intercourse,  as  is  seen 
sometimes  in  cases  of  herpes  in  a  man  with  gonorrhea,  the 
herpetic  ulcers  becoming  chancroids.  As  a  rule,  chancroids 
are  of  venereal  origin,  and  result  from  contact  with  other 
chancroids,  pus,  mucopus,  or  areas  of  ulceration.  There  is 
no  special  germ.  A  chancroid  appears  soon  after  inter- 
course, usually  within  five  days,  always  within  ten  days.  It 
is  first  manifested  by  a  pustule  which  ruptures  and  discloses 
an  ulcer.  This  ulcer  has  sharply-defined  and  undermined 
margins  ;  it  looks  "  punched  out ;  "  the  base  is  gray  and 
sloughy;  the  discharge  is  profuse,  purulent,  foul,  and  auto- 
inoculable,  and  causes  fresh  chancroids  by  flowing  over  the 
parts.  The  area  around  a  chancroid  is  red  and  inflamed,  and 
considerable  pain  is  apt  to  be  complained  of  The  original 
chancroid  spreads  and  new  sores  appear.  The  edge  of  a 
chancroid  is  rarely  indurated  unless  caustics  have  been  used 
or  there  is  mixed  infection  with  syphilis.     Inflammatory  in- 

'  Syphilis  J  by  Alfred  Cooper. 


CHAXCROID.  1 02 1 

duration  fades  gradually  into  the  tissues,  but  the  induration 
of  a  hard  chancre  is  sharply  defined.  Fournier  says  that  a 
chancroid  ma}*  have  a  hard  base  if  the  sore  is  located  in  the 
sulcus  back  of  the  glans,  on  a  lip  of  the  meatus,  or  on  the 
lower  border  of  the  prepuce  of  a  man  with  phimosis,  or  when 
the  ulcer  is  inflamed.  Fournier  maintains  that  the  surgeon 
should  always  ask  if  the  sore  has  been  cauterized  and  how  it 
has  been  treated.  When  a  chancroid  after  a  time  displays 
marked  and  sharply-outlined  induration  it  points  to  mixed 
infection  of  chancroid  and  syphilis.  Chancroids  are  not  fol- 
lowed by  constitutional  s}-mptonis,  but  are  apt  to  be  accom- 
panied by  painful  inflammator\-  buboes  which  are  prone  to 
suppurate.  In  hospital  practice  about  30  per  cent,  of  patients 
develop  buboes.  The  bubo  may  be  one-sided  or  bilateral. 
If  pus  forms,  it  does  not  contain  organisms.  The  adenitis 
of  chancroid  is  due  purely  to  the  absorption  of  toxins.  Cases 
have  been  reported  in  which  non-indurated  sores  were  fol- 
lowed by  syphilis.  It  is  probable  that  a  mixed  infection 
existed,  and  that  induration  was  overlooked,  because  a  papu- 
lar initial  lesion  was  underneath  the  chancroidal  ulcer.  \Vhen 
inflammation  in  chancroids  is  high  a  rapidly  destructive 
ulceration  known  as  pliagcdcna  may  arise,  but  this  process  is 
more  common  in  syphilitic  sores. 

Treatment. — Ordinary  cases  of  chancroid  are  treated  by 
spraying  with  peroxid  of  hydrogen,  dr\'ing  with  cotton,  touch- 
ing each  sore  first  with  pure  carbolic  acid  and  then  with  pure 
nitric  acid,  and  dressing  with  black  wash  or  dusting  with 
iodoform  or  with  calomel.  Every  few  hours  the  patient 
soaks  the  penis  in  hot  salt  water  (a  teaspoonful  of  salt  to 
half  a  pint  of  water),  sprays  the  sores  with  peroxid  of  hydro- 
gen, dries  with  cotton,  and  dresses  wnth  black  wash  or 
dusts  with  iodoform  or  with  calomel.  As  soon  as  granu- 
lation begins  the  sores  should  be  dressed  with  i  part  of 
ointment  of  nitrate  of  mercurj'to  7  parts  of  cosmolin.  ]\Iild 
cases  do  well  without  cauterizing,  peroxid  of  hydrogen  being 
frequently  used  and  a  drying  powder  being  employed.  In 
chancroids  with  phimosis  slit  up  the  foreskin,  burn  the  edges 
of  the  wound  with  pure  carbolic  acid,  and  treat  the  ulcers 
by  cauterization.  A  regular  circumcision  often  fails  because 
of  infection  of  the  stitch-holes.  Phagedena  requires  the  in- 
ternal use  of  iron,  quinin,  and  milk-punch,  and  the  local 
use  of  powerful  caustics  (bromin  or  nitric  acid  or  even 
the  actual  cautery).  In  some  cases  continuous  antiseptic 
irrigation  is  valuable.  When  a  bubo  first  begins  order  rest, 
apply  iodin  or  an  ointment  of  belladonna  or  ichthyol,  and 


1022         DISEASES   OE  GENITO- URINARY  ORGANS. 

make  pressure  by  a  spica  bandage  of  the  groin.  Some 
surgeons  advise  the  injection  of  20—40  minims  of  a  solu- 
tion of  carboHc  acid  (gr.  x  to  the  ounce),  but  we  have 
never  seen  any  benefit  from  it.  Some  inject  a  i  per  cent, 
solution  of  bichlorid  of  mercury,  but  the  proceeding 
causes  intense  pain.  Welander  recommends  the  injection 
of  a  I  per  cent,  solution  of  benzoate  of  mercury.  We 
have  had  no  experience  with  this  method.  If  the  bubo 
persists,  even  though  it  does  not  suppurate,  it  should  be 
completely  excised.  If  pus  forms,  several  methods  of  treat- 
ment are  open  to  us.  Aspiration,  injection  with  a  solution 
of  carbolic  acid,  squeezing  out  the  acid  and  injecting  10 
per  cent,  ointment  of  iodoform  and  glycerin,  and  sealing  the 
opening  with  collodion  (Scott  Helms).  Hayden  makes  a 
puncture,  squeezes  out  the  pus,  washes  out  the  cavity  with 
peroxid  of  hydrogen  and  then  with  corrosive-sublimate  solu- 
tion, injects  warm  iodoform  ointment,  and  dresses  with  cold, 
moist,  corrosive-sublimate  gauze  to  set  the  ointment.  Otis, 
Fontain,  Perry,  and  others  commend  this  plan.  We  have 
often  found  it  to  succeed.  If  the  above-mentioned  plan  fails, 
if  it  is  not  used,  or  if  an  ulcer  or  sinus  exists,  incise,  curet,  cau- 
terize with  pure  carbolic  acid,  cut  away  hopelessly  infiltrated 
skin,  and  pack  the  wound  with  iodoform  gauze.  In  some 
cases  it  will  be  necessary  to  extirpate  fragments  of  gland. 

Phimosis    is    a   condition   of  the   prepuce   that   renders 

retraction  over  the  glans  impossible.    It  is  usually  congenital, 

but  it  may  arise  from  inflammation.     Congenital  phimosis 

causes  retention  of  sebaceous  matter,  which  decomposes  and 

lights  up  inflammation.     The  prepuce  is 

^^g^^^V  apt  to  grow  fast  to  the  glans.     Congeni- 

fj^^^^^^^'X        tal  phimosis  may  induce  irritability  of  the 

|r  -     i  a^Bt I        bladder,   incontinence  of  urine,  prolapse 

\^^^^^^^^ff        of  the  rectum,  and  various  nervous  symp- 

^^^^^^W^  toms.      The    treatment    is    circumcision. 

FiG."4oo-Circumcis-     Ascpticizc  the  parts.     Grasp  the  foreskin 

ion  completed  (Esmarch     and  the  mucous  membrane  with  two  for- 

and  Kowalzig).  ,  .  ^  i  ^     i     ji 

ceps,  draw  the  prepuce  lorward,  catch  the 
skin  (at  the  point  it  is  desired  to  cut)  horizontally  between 
the  arms  of  the  handle  of  a  pair  of  scissors,  and  cut  off  the 
redundant  prepuce.  Retrench  the  excess  of  mucous  mem- 
brane by  cutting  around  with  scissors  one-quarter  of  an  inch 
from  the  glans,  stitch  the  skin  to  the  mucous  membrane 
with  catgut,  and  dress  with  sterile  gauze  (Fig.  400). 

Fracture  of  the  penis,   which   is   a   laceration  of  the 
cavernous  bodies  with  extravasation  of  blood,  occurs  occa- 


SEMINA  L    VESICULITIS.  1 02  3 

sionally  during  coition.  The  treatment  consists  of  cold  and 
bandaging  to  arrest  bleeding,  and  occasionally  incisions  to 
let  out  clot. 

Gangrene  of  the  penis  arises  from  phagedena,  from 
tying  constricting  bands  around  the  organ,  from  fracture 
with  excessive  hemorrhage,  and  from  paraphimosis.  If  ex- 
tensive, it  requires  amputation. 

Cancer  of  the  penis  is  commonest  in  persons  with  phi- 
mosis. In  a  limited  epithelioma  of  the  foreskin  circumcision 
is  performed  and  the  glands  of  the  groin  are  removed ;  if 
cancer  affects  the  glans,  amputation  is  required,  and  the 
glands  are  removed. 

Amputation  of  the  Penis. — Ricord  advised  cutting  off 
the  organ  with  a  single  stroke  of  the  knife,  making  four  slits 
in  the  mucous  membrane  of  the  urethra,  and  stitching  each 
of  these  flaps  to  the  skin.  Treves  splits  the  skin  of  the 
scrotum  along  the  raphe,  separates  the  halves  of  the  scrotum 
down  to  the  corpus  spongiosum,  passes  a  metal  catheter 
down  to  the  triangular  ligament,  inserts  a  knife  between  the 
corpus  spongiosum  and  the  corpora  cavernosa,  withdraws 
the  catheter,  cuts  the  urethra  across,  detaches  the  urethra 
from  the  penis  back  to  the  triangular  ligament,  cuts  around 
the  root  of  the  penis,  divides  the  suspensory  ligament, 
detaches  each  crus  from  the  pubes,  slits  up  the  corpus  spon- 
giosum half  an  inch,  stitches  its  edges  to  the  rear  end  of  the 
scrotal  incision,  introduces  a  drainage-tube,  ligates  the 
vessels,  and  sutures  the  wound. 

Seminal  Vesiculitis. — Inflammation  of  the  seminal 
vesicles  is  due  to  the  extension  of  a  gonorrheal  inflammation 
or  a  pyogenic  process. 

Acute  inflammation  is  made  evident  by  frequent  and  pain- 
ful micturition,  pains  in  the  anus,  rectum,  and  perineum,  and 
possibly  the  hip-joint,  back,  and  thigh.  Defecation  and 
micturition  are  excessively  painful.  Persistent  erections  may 
take  place,  and  in  some  cases  bloody  ejaculations  occur. 
Rectal  examination  detects  the  enlarged  and  tender  vesicles 
external  to  the  lateral  lobes  of  the  prostate  and  on  a  higher 
level. 

Treatment. — Abandon  local  urethral  treatment,  and  treat 
the  patient  as  for  acute  prostatitis. 

Chronic  vesiculitis  may  result  from  the  acute  form  or  may 
come  on  insidiously  in  an  individual  with  gonorrhea.  It  is 
one  of  the  causes  of  chronic  urethral  discharge.  The  patient 
suffers  from  imperative  and  frequent  demands  to  micturate, 
and  he  has  a  gleety  discharge  which  becomes  worse  and 


I024         DISEASES    OF   GENITO-URINA R  Y   ORGANS. 

better,  but  does  not  disappear.  This  chronic  inflammation 
is  beheved  to  persist  because  of  narrowing  of  the  duct,  and 
consequent  incomplete  drainage  of  the  vesicle.  In  chronic 
seminal  vesiculitis  there  is  usually  sexual  weakness,  noc- 
turnal emissions  occur,  and  the  semen  may  contain  blood. 

Treatment. — Treat  the  posterior  urethritis  by  ordinary 
methods.  Use  hot  rectal  enemata.  Milk  the  ducts  by 
Fuller's  method  once  every  seven  days.  The  patient's 
bladder  should  be  full.  He  leans  over  a  chair-back,  the 
knees  being  straight  and  the  body  at  a  right  angle  to  the 
thighs.  The  surgeon  introduces  his  finger  into  the  rectum 
and  makes  pressure  over  the  pubes  with  the  fist  of  the  other 
hand.  The  finger  comes  in  contact  with  the  lower  half  of 
the  vesicle  ;  it  makes  firm  pressure  for  a  moment,  and  is  then 
drawn  slowly  toward  the  duct.  This  stroking  is  repeated 
several  times.  The  other  vesicle  is  treated  in  the  same 
manner.  This  maneuver  empties  the  vesicle  and  hastens 
the  resolution  of  inflammation.  After  the  completion  of  the 
stripping  the  patient  should  micturate,  and  the  bladder  and 
urethra  should  be  irrigated. 

Prostatitis  (see  p.  1008). 

Prostatorrhea. — Just  as  overaction  of  the  glands  of  the 
urethra  constitutes  urethrorrhea,  so  overaction  of  the  glandu- 
lar apparatus  of  the  prostate  gland  constitutes  prostatorrhea. 
Prostatorrhea  is  not  inflammatory,  although  the  prostate 
and  posterior  urethra  are  often  congested,  and  the  latter 
region  is  usually  hyperesthetic.  In  some  cases  urethror- 
rhea exists  with  prostatorrhea.  Prostatorrhea  is  produced 
by  sexual  excess,  masturbation,  ungratified  sexual  desire, 
and  riding  a  bicycle  with  an  improper  seat.  The  condition 
is  usually  accompanied  by  marked  neurasthenia,  and  may  be 
associated  with  spermatorrhea  and  impotence. 

The  patient  notices  a  gray  discharge  after  straining  at 
stool  (defecation-spermatorrhea),  after  violent  exercise,  sex- 
ual excitement,  or  a  bicycle-ride.  Examination  of  the  dis- 
charge shows  it  to  be  prostatic  fluid,  although  spermato- 
zoids  are  sometimes  found.  The  bladder  is  irritable,  and 
there  are  frequency  of  micturition  and  often  some  pain  in  the 
head  of  the  penis  at  the  termination  of  the  act.  Nocturnal 
emissions  may  occur. 

Treatment. — Stop  bad  habits.  If  there  is  urethral  hyper- 
esthesia or  prostatic  congestion,  irrigate  the  bladder  and 
urethra  once  a  day  with  a  solution  of  silver  nitrate  (i  :  4000), 
and  every  fourth  or  fifth  day  introduce  a  cold  sound.  In 
some    cases  the   occasional    instillation    into   the    prostatic 


nypENiROPijy  of  rnE  prostate  gland.     1025 

urethra  of  a  few  drops  of  a  i  per  cent,  solution  of  nitrate  of 
silver  does  good. 

For  the  irritable  bladder  give  hot  hip-baths  at  night.  The 
following  prescription  is  of  service  :  gr.  xv  of  bromide  of 
potassium,  \  dram  of  tincture  of  hyoscyamus  in  \  ounce  of 
cinnamon-water,  three  times  a  day.  Hot  enemata  are  of 
service. 

After  the  h}'peresthesia  of  the  urethra  has  abated,  and 
nocturnal  emissions  have  ceased,  the  neurasthenia  is  treated 
by  cold  sponging  of  the  body  night  and  morning,  the  con- 
tinued use  at  intervals  of  several  da)'s  of  a  large-sized  cold 
sound,  irrigation  every  second  or  third  day  with  silver 
nitrate  (i  :  4000),  and  the  administration  of  strj-'chnin  and 
other  tonics. 

Hypertrophy  of  the  prostate  gland  is  a  senile  change 
occurring  only  after  the  age  of  fifty,  and  being  most  apt  to 
occur  after  the  age  of  sixty.  All  the  lobes  may  be  enlarged 
equally,  all  may  be  enlarged  but  unequally,  or  only  one  lobe 
may  be  enlarged.  Prostatic  hypertrophy  causes  narrowing 
and  lengthening  of  the  urethra,  and  gives  this  tube  a  tor- 
tuous course.  The  opening  of  the  urethra  into  the  bladder 
is  pushed  to  a  higher  level,  and  there  forms  behind  it  a 
pouch  in  which  urine  collects.  This  urine,  which  is  known 
as  residual  urine,  may  collect  in  large  quantity;  it  cannot  be 
voluntarily  expelled,  and  it  is  apt  to  decompose,  producing 
cystitis.  The  bladder  enlarges,  thickens,  and  becomes  fas- 
ciculated, micturition  becoming  very  difficult  and  sometimes 
impossible.  An  enlarged  middle  lobe  will  block  the  flow, 
and  the  bladder  inevitably  becomes  greatly  distended.  In 
hypertrophy  of  the  prostate  the  ureters,  the  renal  pelves, 
and  calyces  may  distend,  and  surgical  kidney  may  develop. 

Symptoms. — In  80  per  cent,  of  all  cases  there  is  only 
slight  inconvenience.  The  stream  of  urine  is  slow  to  start 
and  falls  feebly  from  the  end  of  the  penis.  The  last  drops 
fall  entirely  without  control,  and  there  are  occasional  epi- 
sodes of  nocturnal  frequency  of  micturition.  In  20  per  cent, 
of  all  cases  the  bladder  cannot  be  emptied  entirely,  and 
residual  urine  collects  in  the  bladder.  Frequency  of  mictu- 
rition comes  on,  particularly  at  night;  the  patient  has  to  get 
up  often;  the  bladder  never  feels  empty;  and  cystitis  is  apt 
to  arise.  The  urine,  at  first  acid  and  clear,  becomes  neutral 
and  cloudy,  and  finally  ammoniacal  and  turbid,  and  contains 
bacteria,  mucopus,  precipitates  of  phosphates,  and  blood. 
Above  the  pubes  there  is  aching  pain,  soon  spreading  to  the 
perineum,  which  pain  is  increased  when  the  bladder  is  dis- 


1026         DISEASES    OF   GENITO-URINARY   ORGANS. 

tended  and  during  micturition.  Enlargement  of  the  lateral 
lobes  can  be  detected  by  a  finger  in  the  rectum.  The  rec- 
tum becomes  irritable,  and  piles  form  or  prolapse  of  the 
mucous  membrane  occurs.  Attacks  of  retention  of  urine 
may  occur.  The  bladder  becomes  thin  and  distended,  or 
hypertrophied,  rigid,  and  fasciculated.  In  rare  cases  true 
incontinence  is  caused  by  the  median  lobe  growing  toward 
the  neck  of  the  bladder  and  prev^enting  closure.  The  health 
breaks  down  because  of  pain,  restless  nights,  indigestion, 
and  disorder  of  the  bowels.  The  kidneys  may  become 
involved  (inflammation  of  the  pelves  or  calyces,  or  surgical 
kidney),  and  suppression  may  occur.  Septic  fever  may  arise. 
Calculi  may  form  in  the  bladder.  Death  is  due  to  exhaus- 
tion, suppression  of  urine,  or  septic  cystitis.  A  foul  catheter 
is  the  usual  cause  of  septic  cystitis,  but  micro-organisms 
sometimes  enter  by  passing  along  the  urethral  mucous 
membrane. 

Treatment. — Many  cases  can  be  treated  by  regular  cath- 
eterization. Alexander  has  formulated  several  sound  rules 
as  to  when  catheterization  is  the  proper  treatment.  He 
says,  if  the  patient  is  intejligent-aad  dexterous,  if  cystitis  is 
not  severe^iX_the  amount  of  residual  uiiaeLJsjnaLveryJarge, 
ifobstruction  is  not^great,  if  the  bladder  retains,  considerable 
e2cpubive_ppw:e_r,  and  if  catheterizatioiTls  easy  and  painless, 
rely_jjponjbhis  simple  plan  of  treatment.  Prevent  cystitis 
by  emptying  the  bladder  each  evening  with  a  coude  cath- 
eter. If  there  is  trouble  in  passing  the  catheter,  strengthen 
the  instrument  by  inserting  a  filiform  bougie  as  a  stylet 
(Brinton).  In  some  cases  a  metal  instrument  with  a  large 
curve  is  used.  Teach  the  patient  to  use  the  instrument  him- 
self A  dirty  instrument  may  cause  fatal  infection.  It  is 
true  that  some  people  use  dirty  instruments  for  long  periods 
without  trouble,  but  in  most  cases  there  will  be  trouble  if  it 
is  attempted.  It  is  absolutely  necessary  to  use  only  per- 
fectly aseptic  instruments.  Metal  instruments  are  sterilized 
by  boiling  in  water.  Rubber  catheters  can  be  cleansed  by 
washing  with  soap  and  running  water  and  boiling,  or,  after 
washing,  soaking  in  corrosive-sublimate  solution.  Woven 
instruments  can  be  placed  in  a  glass  cylinder,  the  bottom 
of  which  is  like  a  sieve.  This  jar  is  placed  for  twenty-four 
hours  in  a  vessel  which  contains  formalin.  The  vapor  of 
formalin  is  an  excellent  germicide,  and  does  not  injure  the 
catheter.  After  sterilization  the  instruments  are  kept  ready 
for  use  in  a  glass  cylinder  which  contains  calcium  chlorid.^ 

1  R.  W.  Frank,  in  Berliner  klin.   Woch.,  No.  44,  1895. 


HYPERTROPHY  OF   THE    PROSTATE    GLAND.       IO27 

Guyon  scrubs  the  catheters  with  soap  and  water,  dries  them 
outside  and  inside,  places  them  in  a  sealed  jar,  and  exposes 
them  to  the  vapor  of  sulphurous  acid  for  forty-eight  hours. 
If  there  are  three  ounces  of  residual  urine,  use  the  catheter 
only  at  night.  If  there  are  six  ounces,  use  it  night  and 
morning.  If  there  are  more  than  six  ounces  of  residual 
urine,  add  one  more  catheterization  a  day  for  every  addi- 
tional two  ounces  present  until  the  catheter  is  used  six  times 
in  the  twenty-four  hours.  It  should  never  be  used  oftener 
than  this.  Gradual  dilatation  with  steel  sounds  is  of  benefit, 
but  forcible  dilatation  is  not  advisable.  Tell  the  patient  to 
avoid  violent  exercise,  cold,  damp,  sexual  excitement,  and 
the  use  of  alcoholic  liquors,  prevent  constipation  and  indi- 
gestion, and  direct  him  to  drink  milk  and  plenty  of  water.  A 
hot  hip-bath  at  night  adds  to  his  comfort.  Hot  enemata 
are  of  value.  If  a  large  quantity  of  residual  urine  exists,  or 
if  cystitis  begins,  wash  out  the  bladder  daily  with  boric- 
acid  solution,  or  normal  salt  solution,  or  nitrate  of  silver 
(i  :  12,000),  and  give  urotropin  or  salol  and  boric  acid  by 
the  mouth  (Cystitis,  p.  976).  In  some  severe  cases,  if  a  large- 
sized  rubber  catheter  be  tied  in  the  bladder  for  a  few  days, 
great  relief  is  obtained.  Retention  of  urine  can  be  relieved 
by  the  introduction  of  a  coude  catheter  strengthened  with  a 
whalebone,  of  a  silver  instrument  with  a  prostatic  curve,  or 
by  aspiration.  Most  cases  can  be  kept  comfortable  by  cath- 
eterization, and  only  when  this  fails  should  an  operation  be 
performed.  If^the  symptoms  grow  constantly  worse,  if  the 
suffering  becornes  severe,  if  the  patient  cannot  urinate  with- 
out the  use  of  an  instrument,  if  catheterization  is  painful  or 
impossible,  if  the  patient  is  too  careless  or  ignorant  to  trust 
with  a  catheter,  if  only  a  catheter  of  very  small  size  can  be 
introduced,  if  attacks  of  obstinate  retention  occur,  if  there 
is  persistent  cystitis  or  hematuria,  if  the  residual  urine  grad- 
ually increases  in  amount,  the  bladder  should  be  opened. 

The  perineal  operation  is  as  safe,  or  safer,  than  the  supra- 
pubic, and  can  be  rapidly  performed.  In  this  operation  the 
drainage  is  at  the  lowest  part  of  the  bladder,  and  by  an 
incision  of  the  prostate  gland  the  floor  of  the  urethra  may  be 
lowered  to  the  level  of  the  floor  of  the  bladder  (Dandridge). 
A  large  tube  should  be  worn  during  the  healing  of  the 
wound. 

The  suprapubic  operation  is  easier  than  the  perineal,  it  is 
no  safer,  it  gives  excellent  results  if  temporary  drainage  only 
is  needed.  If  siphon  drainage  is  not  used,  the  opening  is 
better  placed  in   the  perineal   operation,   unless  permanent 


1028         DISEASES    OF   GENITO-URINARY   ORGANS. 

drainag'e  is  required.  After  the  suprapubic  operation  the 
floor  of  the  urethra  cannot  be  brought  level  with  the  floor 
of  the  bladder  by  a  simple  incision  of  the  prostate,  it  can 
only  be  brought  level  by  the  performance  of  prostatec- 
tomy. After  a  suprapubic  cystotomy  has  been  performed  for 
drainage,  the  opening  may  be  kept  permanently  patent  by 
the  retention  of  a  tube  (Hunter  McGuire's  operation).  Fig. 
391  shows  Senn's  tube. 

Suprapubic  prostatectomy  may  be  performed.  After  the 
bladder  is  opened  the  mass  of  prostate  is  enucleated  or  cut 
away  with  scissors  or  with  cutting-forceps.  The  bladder  is 
drained  for  a  time  and  the  suprapubic  cut  is  then  allowed  to 
heal.  McGill's  operation  is  suprapubic  prostatectomy,  the 
gland  being  removed  partly  by  enucleation  and  partly  by  the 
employment  of  cutting  rongeur-forceps.  If  the  suprapubic 
method  of  prostatectomy  is  employed,  it  is  wise  to  use  also  a 
perineal  cut,  in  order  to  control  hemorrhage  and  secure 
good  drainage  (Dandridge).  Fuller  performs  a  suprapubic 
cystotomy,  makes  a  small  incision  through  the  mucous 
membrane  of  the  gland,  enucleates  the  gland  with  the  finger, 
and  drains  through  an  incision  in  the  membranous  urethra. 
Belfield  makes  a  suprapubic  and  a  perineal  cut,  and  with  the 
finger  in  the  perineum  pushes  the  gland  into  easy  reach  of 
the  finger  in  the  bladder. 

Perineal  prostatectomy  may  be  employed.  Some  surgeons 
make  a  curved  incision  across  the  perineum  and  dissect  out 
the  gland.  Nicoll  first  performs  suprapubic  cystotomy, 
opens  the  perineum  down  to  the  prostate,  splits  the  capsule 
of  the  prostate,  inserts  two  fingers  of  the  left  hand  into  the 
bladder,  and  pushes  the  prostate  down  into  the  perineum. 
The  surgeon  enucleates  the  gland  through  the  perineal 
wound  without  damaging  the  mucous  membrane  of  the 
bladder.  Alexander  makes  the  suprapubic  cut  and  uses  it 
for  the  same  purpose  as  Nicoll,  but  he  opens  the  mem- 
branous urethra  on  a  grooved  staff,  enucleates  the  gland, 
and  inserts  a  drainage-tube  through  the  perineal  wound.  Bot- 
tini  of  Padua,  by  means  of  a  special  instrument,  cauterizes 
the  prostate.  This  instrument  is  shaped  like  a  catheter,  and 
carries  a  platinum  blade  which  is  heated  by  an  electric  current. 

Bottini's  galvanocaustic  operation  is  performed  as  follows  : 
The  bladder  should  be  emptied,  irrigated,  and  distended  with 
air  and  the  posterior  urethra  must  be  anesthetized  by  instilla- 
tion of  cocain  or  eucain.  The  current  is  tried  to  see  how 
many  seconds  it  requires  to  heat  the  blade  sufficiently.  The 
current  is  broken,  the  instrument  is  introduced,  the  cooling 


J/yPEKTROPI/y   OF   THE   PROSTATE    GLAXD.       IO29 

current  is  set  in  motion,  and  one  assistant  watches  this  and 
nothing  else.  Turn  on  the  current.  Wait  the  required 
number  of  seconds  for  the  blade  to  become  red  hot  (twelve 
to  fifteen  seconds),  turn  the  screw  at  the  handle,  and  burn  a 
groove  in  the  prostate.  A  groove  should  be  burned  toward 
the  rectum,  one  to  the  side,  and,  if  it  is  thought  desirable,  one 
to  the  opposite  side.  No  groove  should  be  burned  toward 
the  pubes.  When  a  groove  has  been  burned,  return  the  blade 
into  its  sheath,  increasing  the  current  while  doing  so  in  order 
to  keep  the  blade  from  adhering  to  the  tissue,  then  shut  off 
the  current.  After  withdrawing  the  instrument  it  is  not 
necessary  to  introduce  and  retain  a  catheter.  The  patient 
is  confined  to  bed  only  twenty-four  hours,  there  is  rarely 
bleeding  or  fever,  and  the  results  are  good.  It  is  alleged 
that  fibrous  stricture  of  the  neck  of  the  bladder  may  follow 
in  some  cases. ^ 

In  1893  J.  William  White  introduced  the  operation  of 
bilateral  orchidectonn-.  He  proved  that  removal  of  the 
testicles  causes  a  rapid  shrinking  in  an  enlarged  prostate. 
Part  of  this  shrinking  may  be  due  to  diminution  of  conges- 
tion and  edema,  but  true  atrophy  undoubtedly  occurs.  Very 
remarkable  results  have  been  recorded.  In  most  cases  the 
patient  becomes  absolutely  comfortable.  Some  cases  dis- 
pense entirely  with  the  catheter.  Cystitis  ceases,  and  desire 
to  urinate  frequently  becomes  less  marked.  Unilateral 
orchidectomy  has  been  employed,  but  it  is  not  satisfactory. 
Bilateral  division  or  exsection  of  the  vas  deferens,  vasectomy, 
may  be  employed  instead  of  orchidectomy.  This  operation 
was  suggested  by  Mears.  It  is  slower  in  its  results,  but  just 
as  certain.  In  spite  of  the  great  simplicity  of  orchidectomy  the 
mortality  has  been  considerable  (from  11  to  18  per  cent.). 
In  several  instances  mental  disturbance  has  followed  the 
operation,  but  there  is  no  real  evidence  that  it  was  due  to 
this  special  form  of  operation  and  would  not  with  certainty 
have  followed  any  other. 

Among  other  operations  which  have  been  suggested  are 
ligation  of  the  cord  ;  ligation  of  the  vascular  elements  of 
the  cord ;  resection  of  all  the  cord  elements  except  the  vas 
and  its  artery  and  vein  (angioneurectomy) ;  parenchymatous 
injections  of  cocain  into  the  testicles,  the  patient  taking 
tablets  of  prostate  extract  internally ;  and  ligation  of  both 
internal  iliac  arteries. 

^  For  description  of  this  operation,  see  Freudenberg,  in  Berlin,  klin.  Woch., 
No.  46,  1897;  and  Willy  Meyer,  in  Med.  Record  of  March  5,  1S98,  and 
May  12,  1900. 


1030         DISEASES    OF   GENITO- URINARY   ORGANS. 

The  relative  merits  of  these  various  operations  alluded  to 
above  are  in  dispute.  It  is  certain  that  very  many  cases  of 
prostatic  hypertrophy  can  be  kept  comfortable  by  aseptic 
catheterism.  If  this  procedure  fails  or  for  other  reasons 
must  be  abandoned,  a  careful  study  of  the  case  should  be 
made  before  selecting  a  special  operation.  The  Bottini 
operation  is  coming  into  extensive  use.  Some  would  apply 
it  to  almost  any  sort  of  case,  and  claim  that  the  operation  is 
practically  free  from  danger.  Meyer  uses  it  for  any  case  of 
uncomplicated  hypertrophy ;  but  if  the  prostate  is  very  large 
ligates  the  vasa  deferentia  some  weeks  before  cauterizing  the 
prostate,  in  order  to  lessen  the  danger  of  thrombosis. 

A  more  conservative  view  is  that  of  Eugene  Fuller,  who 
doubts  the  permanence  of  the  results  of  the  Bottini  operation, 
fears  that  stenosis  of  the  vesical  neck  may  follow,  and  would 
restrict  the  operation  to  uncomplicated  cases,  not  of  a  grave 
character  and  in  which  the  bladder  has  not  been  seriously 
damaged. 

Of  164  reported  cases,  80  were  cured,  44  were  improved, 
29  were  not  improved,  and  14  were  fatal  (Meyer).  The  real 
status  of  the  operation  has  not  yet  been  definitely  determined. 

Orchidectomy  or  vasectomy  may  produce  great  benefit  or 
may  fail  completely.  These  operations  are  most  serviceable 
in  cases  in  which  the  entire  prostate  is  enlarged  and  soft,  and 
are  not  adapted  to  fibrous  or  myomatous  prostates  nor  to 
conditions  of  valve-like  obstruction  at  the  vesical  neck.  If 
such  an  operation  is  done  early  in  a  case,  the  mortality  is 
small  (3  to  5  per  cent.) ;  if  performed  later,  it  is  considerable 
or  even  large  (10  to  20  per  cent.). 

Prostatectomy  is  an  operation  Avhich  is  followed  by  many 
deaths  (10  to  20  per  cent.).  The  earlier  the  operation  is 
performed  the  safer  it  is. 

In  old  men  with  great  obstruction,  and  with  serious 
disease  of  the  bladder  and  involvement  of  the  kidneys,  per- 
manent suprapubic  drainage  is  usually  the  most  useful 
procedure. 

Retained  and  Malplaced  Testicle. — The  testicle  may 
be  arrested  in  its  passage  to  the  scrotum  :  it  may  remain  in 
the  lumbar  region  ;  it  may  reach  the  internal  abdominal  ring  ; 
it  may  lodge  in  the  inguinal  canal ;  it  may  emerge  from  the 
external  ring,  but  fail  to  enter  the  scrotum ;  or  it  may  pass 
into  unnatural  positions,  as  into  the  perineum  or  the  crural 
canal.  It  may  or  may  not  be  functionally  active.  A  re- 
tained testicle  is  subject  to  attacks  of  orchitis  and  may 
become  sarcomatous.     In  80  per  cent,  of  cases  the  testicles 


TUBERCULOSIS   OF   THE    TESTICLE.  IO31 

have  descended  at  birth  ;  most  often  it  is  the  right  testicle 
which  fails  to  descend.  Sometimes  a  testicle  descends  after 
being  retained  for  months  or  even  years.  In  Keyes'  case 
it  descended  in  the  thirtieth  year.  Late  descent  usually 
causes  hernia. 

Treatment. — If  one  testicle  is  undescended  one  year  after 
birth,  and  the  other  testicle  is  sound,  the  former  should  be 
removed  if  it  is  found  impossible  to  draw  the  gland  into  the 
scrotum  and  fasten  it.  Always  try  to  get  a  retained  gland 
into  the  scrotum,  and  operate  before  the  age  of  puberty. 

Orchitis  is  inflammation  of  the  testicle.  Acute  orchitis 
may  be  due  to  cold,  wet,  traumatism  or  epididymitis,  gout, 
mumps,  rheumatism,  or  a  specific  fever.  The  testicle  is 
round,  swollen,  tender,  and  very  painful,  the  scrotum  is  red 
and  swollen,  the  tunica  vaginalis  is  filled  with  fluid,  and  there 
is  fever.  Cliroiiic  orchitis  results  from  the  acute  form  or  from 
a  chronic  urethral  inflammation,  and  is  almost  always  com- 
bined with  epididymitis.  Chronic  orchitis  may  be  due  to 
syphilis. 

The  treatment  of  the  acute  form  consists  of  rest  in  bed  and 
applications  as  for  epididymitis  (page  1032).  The  chronic 
form  requires  the  removal  of  the  causative  lesion,  the  wear- 
ing of  a  suspensory  bandage,  applications  of  ichthyol  or 
mercurial  ointment,  and  the  administration  of  iodid  of  potas- 
sium by  the  mouth.  Strapping  may  do  good.  Castration 
may  be  required. 

Tuberculosis  of  the  testicle  may  be  primary,  but 
in  most  instances  is  secondary  to  tuberculosis  of  the  prostate, 
bladder,  or  seminal  vesicles.  The  disease  may  be  preceded 
by  pulmonary  tuberculosis,  peritoneal  tuberculosis,  or  tuber- 
cular disease  of  bones  or  joints;  and  primary  tuberculosis  of 
the  testicle  may  be  followed  by  distant  tubercular  lesions. 
In  some  cases  involvement  of  the  prostate  exists,  but  cannot 
be  detected  (latent  tuberculosis  of  the  prostate) ;  in  other  cases 
the  prostate  is  in  a  state  of  subacute  inflammation.  The 
disease  begins  in  one  testicle,  but  in  the  vast  majority  of 
cases  the  other  testicle  becomes  involved  after  a  few  weeks 
or  months.  It  usually  comes  on  gradually ;  but  it  may  begin 
acutely  as  I  have  seen  in  two  instances  during  the  progress 
of  tubercular  peritonitis.  The  disease  is  apt  to  arise  after  a 
slight  injury  or  inflammation,  and  is  most  common  in  young 
men,  but  may  arise  at  any  age.  Nodules  form  most 
commonly  in  the  epididymis,  but  sometimes  in  the  testicles 
as  well.  These  nodules  soften  and  run  together,  and  the 
cord  is  felt  to  be  enlarged.     After  a  time  the  skin  becomes 


1032         DISEASES    OF   GENITO-URINA R  Y   ORGANS. 

red  and  adherent,  gives  way,  and  exposes  a  caseous  break- 
ing-down epididymis  or  testicle.  Except  in  the  acute  cases, 
the  testicle  is  only  slightly,  if  at  all,  painful,  and  tenderness 
is  trivial.     A  small  hydrocele  often  forms. 

Treatment. — Castration  would  appear  useless  if  the 
prostate  is  involved  or  if  other  organs  are  tubercular, 
although  Koenig  maintains  that  after  castration  nodules  in 
the  prostate  may  disappear.  The  best  operation  in  most 
instances  is  the  removal  of  as  much  of  the  testicle  or  epidid- 
ymis as  seems  to  be  diseased.  We  thus  remove  a 
dangerous  area  of  infection.  Before  operating  in  most  cases 
try  the  effect  of  climate,  good  hygiene,  nourishing  diet,  the 
local  application  of  guaiacol,  pressure,  and  heat. 

Orchidectomy  or  Castration  (Excision  of  a  Testicle). — 
In  this  operation  an  incision  is  made  over  the  cord,  com- 
mencing just  outside  the  external  ring  and  running  down 
over  the  base  of  the  tumor.  Clamp  the  cord  and  divide  near 
to  the  ring,  remove  the  testicle,  ligate  the  spermatic  artery 
alone,  and  then  ligate  the  entire  thickness  of  the  cord.  The 
cord  is  ligated  with  chromic  gut.  The  skin  is  sutured  with 
silkworm-gut.  Drainage  is  not  required.  It  is  often  advis- 
able to  remove  a  considerable  amount  of  scrotal  skin. 

Epididymitis,  or  inflammation  of  the  epididymis,  is  usu- 
ally due  to  inflammation  of  the  urethra.  It  is  apt  to  occur  in 
the  stage  of  decline  of  a  gonorrhea,  and  is  announced  by  a 
complete  cessation  of  the  discharge.  It  may  result  from  the 
passage  of  a  urethral  instrument,  the  voiding  of  urine  which 
contains  fragments  of  calculi,  or  as  a  complication  of  pros- 
tatic hypertrophy.  Acute  epididymitis  is  characterized  by 
swelling  about  the  testicle,  pain  in  the  groin,  and  tenderness 
over  the  posterior  part  of  the  testicle.  The  pain  becomes 
acute,  swelling  rapidly  increases,  and  the  constitution  sym- 
pathizes. The  swelling  is  due  partly  to  engorgement  of  the 
epididymis  and  partly  to  fluid  in  the  tunica  vaginalis  (acute 
hydrocele).  Chronic  epididymitis  is  usually  linked  with 
orchitis,  and  it  follows  an  acute  attack  or  a  chronic  urethral 
inflammation. 

Treatment  by  aseptic  puncture  with  a  tenotome,  if  fluc- 
tuation is  marked,  will  relieve  tension  and  pain.  Leech- 
ing over  the  external  abdominal  ring,  use  of  an  ice-bag, 
elevation,  application  of  guaiacol,  and  administration  of  laxa- 
tives and  opium  are  used  in  the  acute  stage.  Application 
of  guaiacol  over  the  cord,  epididymis,  and  testicle  quickly 
relieves  pain  and  distinctly  lessens  swelling.  Three  applica- 
tions a  day  should  be  made  for  one  week.     At  each  applica- 


HYDROCELE. 


lo- 


tion paint  upon  the  scrotum  2  c.c.  of  equal  parts  of  glycerin 
and  guaiacol  (I.  Clifford  Perry),  and  paint  the  scrotum  and 
over  the  external  ring  twice  a  day  with  15  drops  of  guaiacol 
in  I  dram  of  glycerin  or  olive  oil.  Strapping  is  employed 
as  the  inflammation  subsides.  The  treatment  of  the  chronic 
form  is  the  same  as  that  for  chronic  orchitis. 

Hydrocele  (chronic  hydrocele)  is  a  collection  of  fluid 
in  the  tunica  vaginalis  testis.  An  enlargement  of  the  testis 
may  cause  it,  but  in  most  instances  the  cause  is  unknown  and 
no  signs  of  inflammation  exist.  The  fluid  is  albuminous,  but 
it  does  not  coagulate  spontaneously  ;  it  is  thin,  straw-colored, 
and  mav  contain  crvstals  of  cholesterin.     The  testicle  is  at 


Fig.   401. — Varieties   of  hydrocele:   a,  congenital:    b,  infantile:   c,  funicular:   d,  encysted; 

■:■,  vaginal. 

the  lower  and  back  part  of  the  sac.  The  pyriform  mass 
fluctuates,  is  translucent,  grows  from  below  upward,  and  the 
introduction  of  an  exploring-needle  permits  the  yellow  fluid 
to  flow  out. 

Treatment. — Simph'  tapping  the  sac  with  a  trocar  is  only 
palliati\'e ;  air  must  run  in  as  fluid  runs  out,  and  suppura- 
tion may  occur,  which  will  be  dangerous  without  drainage. 
Never  tap  a  rigid  sac.  The  injection  of  irritants  should  be 
abandoned,  as  it  exposes  the  patient  to  serious  danger 
because  of  inflammation  occurring  without  provision  for 
drainage.  Hearn  incises  the  sac,  dries  its  interior  with  bits 
of  gauze,  swabs  it  out  with  pure  carbolic  acid,  packs  it  Avith 
iodoform  gauze,  and  dresses  it  antiseptically.  The  packing 
is  removed  in  twenty-four  hours  and  the  wound  is  allowed 
to  close.  If  the  sac  is  rigid  and  will  not  collapse,  either 
stitch  it  to  the  skin  and  pack  it  or  excise  a  large  portion  of 
its  parietal  layer  and  insert  a  drainage-tube  (Volkmann's 
operation).  It  has  recently  been  proposed  to  tap  the  sac 
with  a  trocar  and  cannula,  to  leave  the  cannula  in  place  as  a 
drain  for  some  days,  and  to  dress  antiseptically. 

Congenital  hydrocele  is  hydrocele  through  an  unclosed 


1034  DISEASES   OE   GENITO-UKINARY   ORGANS. 

funicular  process  into  the  tunica  vaginalis.  If  the  pelvis  is 
raised,  the  fluid  runs  back  into  the  peritoneal  cavity,  from 
which  it  originally  came.  The  treatment  is  the  application 
of  a  truss  to  obliterate  the  funicular  process. 

Infantile  hydrocele  is  a  collection  of  fluid  in  a  funicular 
process  and  the  tunica  vaginalis,  the  funicular  process  being 
closed  above,  but  not  below.  The  treatment  is  to  puncture 
the  sac  and  to  scarify  the  sac-wall  with  a  needle. 

Bncysted  Hydrocele  of  the  Cord. — In  this  variety  the 
funicular  process  is  obliterated  above  and  below,  but  it  is 
patent  between  these  two  points,  and  fluid  collects.  The 
treatment  is  the  same  as  that  for  infantile  hydrocele.  If  this 
fails,  incise  and  pack. 

Funicular  Hydrocele. — The  funicular  process  is  closed 
below,  but  is  open  above.  Raising  the  pelvis  causes  the 
fluid  to  trickle  back  into  the  peritoneal  cavity.  The  treat- 
ment is  the  application  of  a  truss. 

Encysted  hydi^ocelcs  of  the  testicles  and  of  the  epididymis 
may  occur.  Diffused  hydrocele  of  the  cord  is  simply  edema 
of  the  cord.  Hydrocele  of  a  hernia  is  the  distention  of  a 
hernial  sac  with  peritoneal  fluid. 

Hematocele. —  Vaginal  hematocele  is  blood  in  the  tunica 
vaginalis,  the  result  of  traumatism,  a  tumor,  or  the  tapping 
of  a  hydrocele.  There  is  a  pyriform  tumor,  which  fluctu- 
ates, but  which  gradually  becomes  firmer ;  the  scrotum  is 
livid,  and  the  testicle  is  below  and  posterior  to  the  tumor. 
The  encysted  form  of  hematocele  of  the  cord  is  a  hydrocele 
of  the  cord  into  which  bleeding  has  occurred.  The  diffused 
form  is  due  to  extravasation  of  blood  into  the  cellular  sub- 
stance of  the  cord.  Encysted  hematocele  of  the  testicle  is  due 
to  effusion  of  blood  into  an  encysted  hydrocele  of  the  testicle. 
Parenchymatous  hematocele  is  extravasation  of  blood  into 
the  substance  of  the  testicle. 

The  treatment  of  a  recent  case  of  vaginal  hematocele  is 
to  put  the  patient  to  bed,  support  the  scrotum,  and  apply  an 
ice-bag  over  the  testicle.  If  the  swelling  does  not  soon 
abate,  incise,  irrigate,  and  pack. 

Varicocele  is  varicose  enlargement  of  the  veins  of  the 
pampiniform  plexus.  An  irregular  swelling  exists  in  the 
scrotum  and  extends  up  the  cord.  This  swelling  feels  like 
"  a  bag  of  earth-worms  ;  "  it  exhibits  a  slight  impulse  on 
coughing  ;  the  scrotal  skin  and  cremaster  muscle  are  attenu- 
ated ;  the  testicle  lies  at  the  bottom  of  the  swelling  and  is 
softer  and  smaller  than  normal ;  the  swelling  diminishes  on 
lying  down  and  increases  on  standing  or  on  making  pressure 


HEMORRHAGE.  IO35 

o\cr  the  external  ring.  There  is  usually  some  discomfort, 
aching,  or  dragging  in  the  testicle  or  the  groin,  and  even 
neuralgic  pain  in  the  cord.  There  is  sometimes  mental  de- 
pression and  hypochondria. 

Treatment. — In  treating  varicocele,  reassure  the  patient : 
tell  him  there  is  no  real  danger  of  impotence  ;  order  cold 
shower-baths,  correct  constipation  and  indigestion,  give  occa- 
sional tonics,  and  order  the  patient  to  wear  a  suspensory 
bandage.  If  the  testicle  becomes  much  atrophied,  if  the 
pain  and  the  dragging  are  annoying,  or  if  the  mind  is  much 
depressed,  operate. 

XXXVII.  AMPUTATIONS. 

An  amputation  is  the  cutting  off  of  a  limb  or  a  portion 
of  a  limb.  Removal  of  a  limb  or  a  portion  of  a  limb  at  a 
joint  is  known  as  "  disarticulation."  Amputation  may  be 
necessary  because  of  the  existence  of  severe  injury,  of  gan- 
grene, of  tumors,  of  intractable  disease  of  bones  or  joints, 
of  ulcers  w'hich  will  not  heal,  of  traumatic  aneurysm,  etc. 
A  re-amputation  may  be  required  because  of  the  existence 
of  a  defect  or  disease  in  the  stump. 

Classification. — Amputations  are  classified  as  follows  : 
(i)  As  to  time  of  operation  after  the  injury  :  a  priinajy  ampu- 
tation is  performed  soon  after  the  occurrence  of  the  accident 
— as  soon  as  the  sufferer  reacts  from  shock,  and  before  he 
develops  fever ;  a  secondary  amputation  is  performed  some 
time  after  the  accident,  suppuration  having  supervened 
(Stokes);  and  an  hitcnncdiate  amputation  is  performed  dur- 
ing the  existence  of  fever,  but  before  the  development  of 
suppuration.  (2)  As  to  the  situation,  where  the  bone  is 
divided  or  according  to  which  joint  is  cut  through.  (3)  As 
to  the  form  and  situation  of  the  flap. 

In  performing  an  amputation  maintain  rigid  asepsis ;  com- 
pletely remove  the  hopelessly-damaged  portion ;  sacrifice  as 
little  of  the  sound  tissue  as  possible ;  prevent  hemorrhage 
during  the  amputation,  and  carefully  arrest  it  after  the  opera- 
tion ;  have  enough  sound  tissue  in  the  flap  to  cover  the  bone, 
and  enough  skin  to  cover  the  muscles  ;  and  secure  drainage 
at  a  dependent  point. 

HcDiorrliage  is  prevented  by  the  elastic  bandage  of  Esmarch 
(Fig.  402).  In  an  ordinary  case  apply  this  bandage  from  the 
periphery  to  well  above  the  line  of  the  prospective  incision, 
encircle  the  limb  with  the  elastic  band  (not  a  thin  tube),  and 
remove  the  bandage.    The  bandage  and  band,  which  are  asep- 


1036 


AMPU7-A  7'IOXS. 


ticized  before  using,  are  applied  to  the  limb,  which  has  been 
carefully  sterilized.  After  the  band  has  been  applied  the  limb 
should  not  freely  or  forcibly  be  moved,  because  of  the  danger 
of  tearing  muscles  which  are  firmly  set  by  the  compressing 
band.  When  elastic  compression  is  used  in  an  operation  the 
surgeon    should  be  very  careful   to   tie   every  visible  vessel. 


Fig.  402. — Esmarch's  elastic  bandage. 


Fig.  403. — Application  of  tourniquet. 


The  paralysis  of  the  small  vessels  induced  by  pressure  often 
prevents  bleeding,  and  unless  their  mouths  be  found  and  the 
vessels  be  tied  reactionary  hemorrhage  will  occur.  Reac- 
tionary hemorrhage  is  the  great  danger  after  the  use  of  the 
Esmarch  bandage,  and  paralysis  or  sloughing  may  also  fol- 
low its  employment.  If  there  be  an  area  of  suppuration  or 
of  gangrene  or  an  extra-osseous  malignant  growth,  do  not 
apply  the  bandage  as  directed  above.  One  bandage  can 
be  appHed  from  the  periphery  to  near  the  lower  border  of 
the  area  of  growth  or  infection,  and  another,  from  near  the 
upper  border  of  this  area,  up  the  limb.  The  contents  of 
the  area  (tumor-cells  and  fluid  or  septic  products)  are  not 
squeezed  into  the  circulation.  In  cases  like  the  above  many 
surgeons  hold  the  extremity  in  a  vertical  position  for  five 
minutes,  lightly  stroking  it  toward  the  body  with  the  hand, 
and  at  once  apply  the  constricting  band.  As  a  matter  of 
fact,  this  plan  satisfactorily  empties  the  limb  of  blood,  and 
it  is  not  necessary  in  any  case  to  force  the  blood  out  by 
elastic  compression.     Some  surgeons  prefer  the  tourniquet. 


CIRCULAR   METnOD. 


lO 


J/ 


Figs.   404   and    405    show  two    forms    of  tourniquet.       To 
apply  Petit's  tourniquet,  place  the  plates  in  contact,  apply 


Fig.  404. — Petit's  spiral  tourniquet. 


Fig.  405. — Charriere's  tourniquet. 


a  small  firm  compress  over  the  artery  and  a  broad  thick 
compress  over  the  outer  surface  of  the  limb,  buckle  the 
tapes  around  the  limb  so  that  the  plate  is  over  the  broad 
pad,  and  tighten  the  tourniquet  by  separating  the  plates 
with  the  screw  (Fig.  403).     When  a  tourniquet  is  applied  to 


ana  saws 


for  amputations. 


arrest  bleeding  during  transportation,  bandage  the  limb,  sew 
the  compress  pad  to  a  bandage,  and  place  the  plates  of 
the  instrument  over  the  pad.  Signorini's  horseshoe  tourni- 
quet may  be  used  upon  the  brachial  artery.  In  hip-joint 
and  shoulder-joint  amputations  Wyeth's  pins  are  passed, 
and  after  the  limb  is  emptied  of  blood  the  band  is  fastened 
above  them.     These  pins  prevent  the  bands  from  slipping. 

The  instruments  and  appliances   required  are  Esmarch's 
apparatus    or   tourniquet,  amputating-knives,  a    bone-knife, 


I038 


AMPUTA  TIONS. 


scalpels,  saws,  a  lion-jawed  forceps,  bone-cutting  forceps, 
a  periosteum-elevator,  retractors  of  linen,  dissecting-,  hemo- 
static, and  toothed  forceps,  a  tenaculum,  an  aneurysm-needle, 
a  probe,  scissors,  needles,  ligatures,  sutures  of  silkworm-gut, 
dressings,  bandages,  and  solutions.  A  retractor  has  two  tails 
for  the  thigh  and  arm  and  three  tails  for  the  leg  and  fore- 
arm :  it  is  made  by  taking  a  piece  of  muslin  eight  inches 
wide  and  twelve  inches  long  and  cutting  tails  on  one  side 
eight  inches  in  length. 

Methods  of  Amputating. — Circular  Method  (Fig. 
407). — The  surgeon  should  stand  to  the  right  of  the  limb 
and  use  a  long  amputating-knife 
which  cuts  from  heel  to  point.  After 
an  assistant  has  retracted  the  skin 
the  operator  divides  the  soft  parts 
by  a  series  of  circular  cuts.  Do  not 
cut  at  once  to  the  bone,  but  divide 
the  skin  and  subcutaneous  tissues. 
At  the  retracted  edge  of  the  first  cut 
divide  the  superficial  muscles,  and 
after  these  muscles  retract  divide  the  deep  muscles.  Incise 
the  periosteum  with  a  bone-knife,  push  up  the  periosteum 
with  an  elevator,  and  after  the  application  of  the  retractors 
saw  the  bone,  starting  the  saw  from  heel  to  point.  A 
periosteal  flap  can  be  made  to  cover  the  end  of  the  bone, 
but    it   is    unnecessary.      In   this    amputation    is    formed    a 


Fig.  407. — Amputation  of 
arm  by  the  circular  method 
(Druitt). 


Fig.  408. — Circular  amputation  :  dissecting  up  the  skin-flap  (Esmarch). 

cone  whose  apex  is  the  bone  and  whose  base  is  the  skin- 
edge.  In  one  form  of  circular  amputation  {anipiitation 
a  la  manchette)  the  retracted  skin  is  cut  by  a  circular 
sweep  of  the  knife,  a  cuff  of  skin  and  subcutaneous  tissue  is 
freed  and  turned  up,  and  the  muscles  are  cut  circularly  at 
the  edge  of  the  turned-up  cut  (Fig.  408).     The  pure  circular 


FLAP  METHOD. 


1039 


amputation  is  performed  on  the  arm  and  the  thigh ;  the 
amputation  a  la  vianchcttc  is  performed  chiefly  through  the 
wrist  and  the  lower  forearm. 

Modified  Circular  Method. — In  this  operation  the  cir- 
cular skin-cut  ma}'  be  modified  by  making  a  vertical  incision 
to  join  the  first  wound,  the  muscles  being  cut  by  a  circular 
sweep  or  by  making  two  vertical  skin-incisions.  Liston's 
modification  consists  in  dissecting  up  two  short  semilunar 
integumentary  flaps  and  in  dividing  the  muscles  circularly. 
This  is   known  as  the  "  mixed  method "    (Fig.  409).     The 


Fig.  400.— Modified  circular  amputation  :  skin-flaps  and  circular  through  muscles 
(Esmarch). 

modified  circular  can  be  used  upon  the  thigh,  the  leg,  the 
arm,  and  the  forearm. 

Elliptical  Method. — This  method  stands  midway  between 
the  circular  operation  and  the  operation  by  a  single  flap. 
An  elliptical  incision  is  made  through  the  skin  and  subcu- 
taneous tissues,  the  tissues  are  pushed  up  or  turned  back, 
and  the  muscles  are  divided  circularly  or  cut  partly  by 
transfixion.  This  method  is  employed  particularly  in  certain 
disarticulations. 

Oval  or  Racket  Method. — In  an  oval  amputation  the 
incision  through  the  skin  and  subcutaneous  tissue  is  an  oval 
with  a  pointed  end  or  a  triangle,  and  the  other  parts  down 
to  the  bone  are  cut  from  without  inward.  When  a  longi- 
tudinal incision  down  to  the  bone  (Fig.  415,  a,  b)  extends 
from  the  point  of  the  oval  {a,  b)  the  operation  is  called 
the  "racket"  amputation.  If  the  longitudinal  cut  joins 
a  circular  cut,  the  operation  is  known  as  a  "T"  am- 
putation. The  oval  or  racket  operation  is  performed  at  the 
metacarpophalangeal,  metatarsophalangeal,  and  shoulder- 
joints  ;  the  T  operation  may  be  performed  at  the  hip-joint. 

Flap  Method. — A  flap  may  be  composed  of  skin  only  or 
of  both  skin  and  viusck,  but  the  skin-flap  must  always  be 


1 040  A  MP  UTA  T/OXS. 

longer  than  the  muscle-flap,  so  that  the  latter  will  be  covered 

by  it.  A  flap  containing  much 
muscle  heals  badly,  but  the  best 
flap  has  a  moderate  amount  of 
muscle  (enough  skin  to  cover 
the  muscle  and  enough  muscle 
to  cover  the  bone).  Flaps  may 
be  single  or  double.  Double 
flaps  may  be  lateral  or  antero- 
posterior, square  or  \i-shaped, 
equal  or  unequal,  and  they  may 
be  cut  by  transfixion  (Fig.  410), 

Fig.  410. — Amputation  of  the  thigh  by       ,  ,,.  f  -.t         i_    ■  i 

transfixion  (Gross).  by  cuttmg  trom  without  mward, 

by  dissection,  or  by  cutting  the 
skin  from  without  inward  and  the  muscles  by  transfixion. 
When  an  amputation  is  completed,  tie  the  main  vessels, 
pull  down  the  nerves  and  cut  them  high  up,  smooth  the 
flaps,  take  off  the  constricting  band,  and  after  arresting 
hemorrhage  apply  sutures.  In  some  cases  the  deep  parts 
are  stitched  with  a  continuous  catgut  suture  and  the  super- 
ficial parts  are  closed  with  silkworm-gut ;  in  other  cases  the 
deep  parts  are  not  stitched  at  all,  the  skin  alone  being 
sutured  with  silkworm-gut.  Drainage-tubes  should  be  used 
except  in  amputations  of  the  fingers  and  toes. 

Special  Amputations. 

Fingers  and  Hand. — In  amputating  the  thumb  and  in- 
dex finger  save  every  possible  scrap  of  tissue.  In  either  of  the 
fingers,  if  it  be  necessary  to  amputate  above  the  middle  of  the 
middle  phalanx,  the  attachment  of  the  flexor  tendons  will  be 
cut  off  and  the  finger  will  be  liable  to  project  directly  back- 
ward, so  that  it  is  better  with  these  fingers  either  to  disarticu- 
late at  the  metacarpal  joints  or  to  stitch  the  flexor  tendons  to 
the  periosteum.  The  flexor  tendons  have  fibrous  sheaths  ex- 
tending from  the  proximal  end  of  the  distal  phalanx  to  the 
metacarpophalangeal  articulations,  these  sheaths  being  thin 
and  collapsible  opposite  the  joints,  but  being  thick  and  rigid 
opposite  the  shafts  of  the  bone.  The  fibrous  sheath  is  known 
as  the  tlteca,  and  when  it  is  cut  in  an  amputation  it  should  be 
closed,  otherwise  it  may  carry  infection  to  the  palm  of  the 
hand.  The  theca  does  not  exist  over  the  distal  phalanx,  and 
it  is  not  distinctly  visible  over  the  joint  between  the  distal  and 
middle  phalanges.  To  effect  closure  over  the  shaft  of  a  bone, 
strip  up  the  periosteum  and  pass  catgut  sutures  verticaHy 


FOREARM. 


1041 


Fig.  411. — Amputation 
of  the  finger. 


through  the  theca  and  the  periosteum  (Treves).  In  amputa- 
tion of  the  fingers  and  the  thumb  an  Ksmarch  bandage  is  un- 
necessary, though  pressure  may  be  made  upon  the  arteries 
at  the  wrist.  Only  two  or  three  Hgatures  are  necessar}-. 
Close  with  a  \&xy  few  sutures,  so  as  to  favor  drainage  between 
the  threads. 

The  distal  phalanx  is  best  removed  by  a  long  palmar  flap 
(Fig.  41 1,  a).  The  palmar  flap  (a)  is  marked  out  by  cutting 
through  the  skin  and  subcutaneous  tissue. 
The  incisions  are  next  carried  to  the  bone, 
the  flap  is  dissected  from  the  bone,  the  fin- 
ger is  strongly  flexed,  a  transverse  incision 
(b)  is  carried  across  the  dorsum  on  a  level 
with  the  base  of  the  third  phalanx,  the  soft 
parts_  are  pushed  back,  the  joint  is  opened,  the  lateral  liga- 
ments are  cut  from  within  outward,  the  third  phalanx  is 
forcibly  extended,  and  the  remaining  structures  are  cut  from 
below  upward.  The  middle  phalanx  can  be  removed  by  the 
same  method  (c).  The  proximal  phalanx  can  be  removed 
by  a  long  palmar  flap  or  by  a  long  palmar  and  a  short  dorsal 
flap  (d,  e). 

Disarticulation  of  a  metacarpophalangeal  joint  is 
best  performed  by  the  oval  or  racket  method.  The  incision 
upon  the  dorsum  (.\)  is  begun  just  above  the  head  of  the 
metacarpal  bone,  is  carried  down  to  beyond  the  base  of  the 
phalanx,  and  involves  the  skin  only  (Fig.  412).  One  incision 
sweeps  around  the  finger  at  the  level  of  the  web,  going  only 
through  the  skin  (b);  the  finger  is  extended  and  the  palmar 
cut  is  carried  to  the  bone  ;  each  lateral  incision  is  carried  to 
the  bone  while  the  finger  is  bent  in  the 
opposite  direction,  the  flaps  are  dissected 
back  to  the  joint,  the  finger  is  strongly 
extended,  the  joint  is  opened  from  the 
palmar  side,  and  disarticulation  is  effected. 
Cutting  off  the  head  of  the  metacarpal 
bone  improves  the  appearance  of  the 
stump  but  weakens  the  hand,  hence  in  a 
workingman  it  must  not  be  done  unneces- 
sarily. If  it  is  necessary  to  remove  a 
metacarpal  bone,  the  incision  (c)  is  made 
from  the  carpometacarpal  joint. 

Amputation  of  the  thumb  through 
its  distal  or  proximal  phalanx  is  performed 
identically  as  is  an  amputation  of  a  finger. 
Amputation  of  the  thumb,  with  a  portion  or  the  whole  of  its 

6fi 


Fig.  412. — A,  disarticu- 
lation of  a  metacarpopha- 
langeal joint ;  c,  amputa- 
tion of  a  finger  with  the 
metacarpal  bone. 


1 042  AMPUTATIONS. 

metacarpal   bone,  is   performed   by  the   oval   or   racket   in- 
cision. 

Amputation  of  the  wrist -joint  can  be  done  by  the 
circular  method  or  by  a  double  flap.  In  the  double-flap 
amputation  a  dorsal  flap  is  made  by  carrying  a  semilunar 
skin-incision  between  the  styloid  processes ;  the  skin  is  lifted, 
the  wrist  is  forcibly  flexed,  the  joint  is  opened  by  a  trans- 
verse cut,  and  a  long  semilunar  palmar  flap  which  includes 
only  the  skin  and  fascia  is  made  by  dissection. 

Amputation  through  the  forearm  may  be  effected 
by  the    circular  method   (Fig.    408),  the    modified  circular, 

or  the  flap  operation.     An  ex- 
cellent    plan    is     to     make    a 
semilunar  dorsal  skin-flap  and 
Fig.  413 -Modified  circular  amputation     a    Semilunar    skin-flap    on    the 

of  the  forearm  (Bryant).  flg^^^j.     surfaCC.        The     flapS     are 

raised,  the  muscles  are  cut  circularly  (Fig.  413),  the  interos- 
seous space  is  cleared  with  the  knife,  a  three-tailed  retractor  is 
applied,  the  periosteum  is  pushed  up,  and  the  bones  are  sawn 
half  an  inch  above  the  flap.  In  sawing  the  bones,  start  the 
saw  upon  the  radius,  draw  it  from  heel  to  point,  make  a  fur- 
row on  the  radius  and  ulna,  and  saw  both  bones  at  same  time. 
After  sawing,  cut  away  any  irregular  edge  with  bone-pliers. 
In  the  lower  third  Teale's  amputation  may  be  done,  the  dor- 
sal flap  being  the  long  one.  In  Teale's  amputation  rectangu- 
lar flaps  are  made.  The  long  flap  is  equal  in  width  and  length 
to  one-half  the  circumference  of  the  limb  at  the  point  where 
it  is  to  be  sawn.  The  short  flap  is  equal  in  width  to  the  long 
flap,  but  is  only  one-fourth  its  length.  The  two  longitudinal 
cuts  are  at  first  taken  only  through  the  skin,  but  the  two 
transverse  cuts  go  at  once  to  the  bone.  The  flaps  are  dis- 
sected up  from  the  interosseous  membrane  and  the  bone.  In 
the  middle  or  the  upper  third  of  a  fleshy  arm  two  semilunar 
skin-flaps  can  be  cut  from  without  inward,  and  the  muscle 
can  be  cut  by  transfixion. 

Disarticulation  of  the  elbow-joint  can  be  done  by 
the  elliptical  method  or  by  a  long  anterior  and  short  poste- 
rior flap.  In  the  latter  operation  the  forearm  is  partly  flexed 
and  a  skin-cut  marks  out  a  long  anterior  flap,  the  knife  being 
entered  opposite  the  external  condyle  and  being  withdrawn 
one  inch  below  the  internal  condyle.  The  muscles,  which 
are  bunched  forward,  are  cut  by  transfixion.  A  posterior 
semilunar  flap  is  made,  which  separates  the  attachments  of 
the  radius,  the  ulna  is  cleared,  and  the  triceps  is  cut  at  its  in- 
sertion (Bell).  Gross  advocated  sawing  through  the  olecranon 
and  the  inner  trochlear  surface. 


THE   ARM. 


104- 


Amputation  of  the  arm  is  best  performed  b\-  marking 
out  with  a  knife  two  equal  semilunar  anteroposterior  flaps, 
the  first  cut  being  carried  through  the  skin  alone,  the  mus- 
cles being  then  transfixed  with  a  long  knife.  Teale's  method 
is  shown  in  Fig.  204.  The  circular  or  the  modified  circular 
amputation  may  be  performed. 

Disarticulation  at  the  Shoulder-joint.— In  this  oper- 
ation  W'yeth's  pins  are  passed  to  hold  the   Esmarch  band 


Fig.  414. — Use  of  Wyeth's  pins  in  amputation  at  the  shoulder-joint.    The  acromion  is  marked 
by  a  black  line  (Keen). 

in  place.  The  anterior  pin  is  entered  at  the  middle  of  the 
lower  margin  of  the  anterior  axillary  fold,  and  emerges  one 
inch  within  the  tip  of  the  acromion.  The  posterior  pin 
is  entered  at  a  corresponding  point  on  the 
posterior  axillai'}'  fold,  and  emerges  more 
posteriorly  than  the  first  pin  and  an  inch 
within  the  tip  of  the  acromion.  The  Esmarch 
band  is  applied  abo\'e  the  pins  (Fig.  414). 

Larrey's  Operation. — In  this  method  of 
shoulder-joint  disarticulation  the  limb  is  held 
from  the  side  and  an  incision  is  made  down 
to  the  bone,  the  incision  beginning  just  below 
and  in  front  of  the  acromion  and  running 
vertically  for  four  inches  down  the  outer  sur- 
face of  the  arm  (Fig.  415,  a  b).  From  the 
center  of  this  incision  an  oval  incision  {c  d,  c  c) 
is  carried  around  the  arm,  the  inner  aspect  of  the  o\-al  reaching 
as  low  as  the  lower  end  of  the  vertical  cut.  The  oval  incision 
at  first  involves  only  the  skin  and  subcutaneous  tissues.  The 
anterior  structures  are  divided  close  to  the  bone,  and  the 


Fig.  415. — Ampu- 
tation at  the  shoul- 
der-joint :  a,b,c,d,c, 
Larrey's  operation  ; 
f,  g',  Dupuytren's 
operation. 


I044 


AMPUTA  TIONS. 


posterior  structures  are  next  cut.  To  disarticulate,  cut  the 
capsule  transversely  upon  the  head  of  the  bone  ;  while  the 
arm  is  rotated  outward  cut  the  subscapularis,  and  while  the 
arm  is  rotated  inward  cut  the  supraspinatus  and  infraspi- 
natus and  the  teres  minor.  Cut  away  any  tissue  holding  the 
humerus  to  the  body ;  cut  away  hanging  nerves,  capsule- 
fragments,  and  tissue-shreds,  and  sew  up  the  wound  verti- 
cally. Bell  advises  an  oval  incision  with  a  racket  handle. 
Spence  used  an  anterior  racket  incision. 

Dupuytren's  Method. — In  Dupuytren's  shoulder-joint 
disarticulation  a  U-shaped  flap  is  marked  out  by  a  skin- 
incision  (Fig.  415,/^).  If  the  amputation  is  to  be  at  the 
right  shoulder,  the  arm  is  carried  across  the  chest ;  the  knife 
is  entered  at  the  root  of  the  acromion,  follows  the  margin 
of  the  deltoid,  and  is  withdrawn  at  the  coracoid  process,  the 
arm  being  gradually  abducted  and  pulled  off  from  the  chest. 
If  the  left  shoulder  is  to  be  amputated,  the  procedure  is 
reversed  (Treves).  The  knife  now  cuts  through  the  deltoid 
and  raises  a  flap  composed  of  this  muscle,  the  shoulder-joint 
is  exposed,  and  disarticulation  is  effected  as  in  Larrey's 
method.  The  knife  is  passed  down  back  of  the  bone  and  a 
short  internal  flap  is  cut.  Lisfranc's  amputation  is  by  trans- 
fixion with  the  formation  of  an  anterior  and  a  posterior  flap, 
and  can  be  performed  very  rapidly,  but  only  a  most  skilful 
surgeon  should  attempt  it. 

Amputation  of  the  Bntire  Upper  Extremity. — 
Berg-er's  Amputation, — This  operation  is  an  amputation 
above  the  shoulder-joint.  By  it  are  removed  the  arm,  the 
scapula,  and  a  portion  of  or  the  entire 
clavicle.  It  is  occasionally  employed 
in  cases  of  malignant  disease  and  of 
severe  injury.  The  operation  is  at- 
tended with  profuse  hemorrhage,  and 
as  a  preliminary  the  subclavian  vessels 
should  be  ligated.  The  incisions  must 
be  varied  according  to  the  necessities 
of  the  case.  In  this  operation  Berger 
divides  the  clavicle  at  the  junction  of 
its  outer  and  middle  thirds,  and  re- 
sects the  middle  third  of  the  bone ; 
ligates  and  divides  the  subclavian  ves- 
sels ;  cuts  the  anterior  flap  (Fig.  416) ; 
divides  the  brachial  plexus ;  marks  out 
the  posterior  flap  ;  and  completes  the 
operation  by  dividing  the  structures  which  hold  the  shoulder- 


t'lG.    416. — Removal    of  the 
whole  upper  extremity. 


THE    TOES   AND   FOOT. 


1045 


Fig.  417. — Ampu- 
tation of  the  toes 
with  and  without  the 
metatarsal  bones. 


blade  to  the  chest.     It  is  in  this  last  step  that  bleeding  is 
profuse. 

Amputation  of  the  Toes  and  the  Foot. — Only  in  the 
great  toe  is  partial  amputation  performed,  and  it  is  effected 
by  the  formation  of  a  long  plantar  flap,  just  as  a  long  palmar 
flap  is  formed  from  the  finger.     Amputation 
at    the    metatarsophalangeal   joints    is    per- 
formed by  an  oval  or  racket  incision  (Fig. 
417,  c).     Amputation  of  a  toe  with  removal 
of  its  metatarsal  bone  is  shown  in  Fig.  417, 
a  b  and  d  c. 

Amputation  at  the  Tarsometatarsal 
Articulation. — Lisfranc's  Method  (after 
Treves). — In  order  to  amputate  the  right 
foot  by  this  method  begin  an  incision  on  the 
outer  border  of  the  foot,  behind  the  tubercle 
of  the  fifth  metatarsal  bone;  carry  the  inci- 
sion forward  one  inch  and  sweep  it  across 
the  foot  half  an  inch  below  the  tarsometa- 
tarsal articulations;  bring  the  incision  to  the 
inner  edge  of  the  foot,  half  an  inch  in  front 
of  the  tarsal  articulation  of  the  big  toe,  and  carry  the  cut 
straight  along  the  inner  margin  of  the  foot  until  it  reaches  a 
point  three-fourths  of  an  inch  above  the  articulation  of  the 
metatarsal  bone  of  the  great  toe.  A 
very  short  semilunar  dorsal  skin-flap  is 
thus  formed.  After  the  skin-flap  is  dis- 
sected back  for  a  quarter  of  an  inch  the 
tendons  are  divided,  and  the  flap,  which 
now  contains  all  the  soft  parts,  is  dis- 
sected back  to  above  the  joint.  A  long 
plantar  flap  is  cut,  reaching  from  the 
origin  of  the  first  flap  to  the  necks  of  the 
metatarsal  bones.  The  skin-flap  is  dis- 
sected up  until  the  hollow  behind  the 
heads  of  the  metatarsal  bones  is  reached, 
when,  with  the  toes  in  extension,  the 
tendons  are  cut  across  and  a  flap  com- 
posed of  all  the  soft  parts  is  dissected 
up  to  above  the  tarsometatarsal  joint. 
Fig.  418  shows  the  line  of  Lisfranc  at  the  tarsometatarsal 
articulation.  The  joint  is  opened  from  the  outer  side  ac- 
cording to  the  following  rule :  in  separating  the  fifth  meta- 
tarsal direct  the  edge  of  the  knife  toward  the  distal  end  of 
the   first    metatarsal;    in    separating    the    fourth    metatarsal 


Fig.  418. —  Lines  in  am- 
putations of  the  foot 
(Gross). 


1046 


AMPUTATIONS. 


direct  the  knife  toward  the  middle  of  the  first  metatarsal; 
in  separating  the  third  metatarsal  carry  the  knife  almost 
directly  across.  The  separation  is  facilitated  by  bending 
down  the  front  of  the  foot,  and  at  the  same  time  the 
tendons  of  the  peroneus  brevis  and  tertius  are  divided. 
Open  the  joint  between  the  first  metatarsal  and  the  inner 
cuneiform  bone,  turning  the  knife  toward  the  middle  of 
the    shaft    of  the    fifth    metatarsal,  and    at    the    same   time 


Fig.  419. —  Lisfranc's  amputation  :  first  step  (Guerin). 

divide  the  tibialis  anticus  muscle.  Treves  says  that  in 
disarticulation  of  the  second  metatarsal  the  knife  is  to  be 
held  as  a  trocar,  it  is  to  be  thrust  between  the  base  of  the 
first  and  second  metatarsal  bones  until  the  point  strikes 
bone  (Fig.  419),  and  is  then  to  be  raised  to  a  perpendicular 
and  the  cut  is  to  be  made  toward  the  external  malleolus 
to  sever  the  ligament  of  Lisfranc  (Fig.  420).  Divide  any 
remaining  ligaments,  and  also  the  tendon  of  the  peroneus 
longus  muscle.    The  skin-incisions  in  the  left  foot  are  begun 


Fig.  420. — Lisfranc's  amputation  :  second  step  ((juerin). 

on  the  inner  side,  and  in  disarticulating  the  tarsal  joint  of 
the  great  toe  is  first  opened.  Fig.  42 1  shows  the  parts  after 
disarticulation  at  the  line  of  Lisfranc. 

Hey's  Method.— In  Hey's  method  the  incision  is  practi- 
cally the  same  as  that  for  Lisfranc's  amputation.  The  four 
external  metacarpal  bones  are  disarticulated,  but  the  first 
metatarsal  is  removed  by  sawing  a  portion  of  the  internal 
cuneiform  bone.   Guerin  advised  sawingf  all  the  bones  across. 


THE  ANKLE-JOIXT. 


1047 


Skey  advised  the  di\-ision  of  the  head  of  the  second  meta- 
tarsal.    Fig.  418  shows  the  hne  of  Hey. 

Amputation  through  the  Middle  Tarsal  Joint. — 

Chopart's  Amputation.  —  Make  a  transverse  incision 
through  the  skin  of  the  instep,  two  inches  below  the 
ankle-joint;  cut  the  tendons  and  muscles,  expose  the  tar- 
sus, and  make  on  eacli  side  a  small  longitudinal  incision 
reaching  to  below  and  in  front  of  the  corresponding  malle- 
olus. The  flap  thus  formed  is  retracted.  The  plantar  flap 
is  made  as  in  Lisfranc's  amputation.  Open  the  astragalo- 
scaphoid  joint,  then  the  calcaneocuboid  joint,  and  disarticu- 
late. Fig.  418  shows  the  line  of  Chopart.  Fig.  422  shows 
the  parts  after  Chopart's  disarticulation.  In  anipiitatioii 
th'oiigJi   the  tavs2is  Forbes  of  Toledo  advises   making  flaps 


Fig.  421. — The  parts  after  Lisfranc's 
amputation  (Bernard  and  Huette). 


Fig.  422. — The  parts  after  amputation  by  Cho- 
part's method  (Bernard  and  Huette). 


as  in  Chopart's  amputation,  disarticulating  the  scaphoid 
from  the  cuneiform  bones,  and  sawing  through  the  cuboid. 
Fig.  418  shows  the  line  of  Forbes. 

Amputation  at  the  Ankle-joint. — Syme's  Method. — 
The  foot  is  held  at  a  right  angle  to  the  leg,  and  a  skin- 
incision  is  carried,  from  just  below  the  external  malleolus, 
straight  across  or  a  little  backward  across  the  sole  to  a 
corresponding  point  on  the  opposite  side.  Do  not  take  this 
incision  near  to  the  inner  malleolus,  as  to  do  so  will  endanger 
the  posterior  tibial  artery.  The  incision  is  carried  to  the 
bone,  the  flap  being  pushed  back  and  separated  from  the 
bone  by  means  of  a  strong  knife  and  the  thumb-nail  until 
the  tuberosity  of  the  os  calcis  has  been  reached.  The  foot 
is  now  extended  and  a  transverse  cut  is  made  across  the 
dorsum,  joining  the  two  ends  of  the  first  incision ;  the  ankle- 
joint  is  opened,  the  lateral  ligaments  are  cut,  disarticulation 
is  effected,  and  the  foot  is  final!}-  completely  removed  b}- 


1048 


AMPUTA  TIONS. 


sev'cring  the  tendo  Achillis.  A  thin  piece  of  bone  including 
both  malleoH  is  sawn  from  the  tibia  and  fibula.  The  flap  is 
perforated  posteriorly  to  secure  drainage. 

Pirogoff 's  Method. — Flex  the  foot  to  a  right  angle  with 
the  leg.  "  Make  an  incision  from  the  tip  of  the  internal 
malleolus  across  the  sole,  a  little  in  front  of  the  long  axis  of 
the  tibia,  to  a  point  in  front  of  the  apex  of  the  external 
malleolus  down  upon  the  bone."  ^  Dissect  the  flap  back- 
ward from  the  calcaneum  for  a  quarter  of  an  inch,  but  do 
not  dissect  the  flap  from  the  posterior  portion  of  the  os 
calcis.  Join  the  extremities  of  the  first  incision  by  another 
cut  w^hich  reaches  to  the  bone,  and  which  is  "  half  an  inch 
in  front  of  the  lower  extremity  of  the  tibia  "  (Br\'ant) ;  but 
saw  off  this  bony  projection  obliquely  and  leave  it  adherent 


Fig.  423. — Lines  of  section  of  the  os  calcis  and  the  bones  of  the  leg  in  PirogofTs  ampu- 
tation. 


to  the  tissues.  The  saw  is  used  after  disarticulation  of  the 
ankle-joint;  it  is  passed  behind  the  astragalus,  cutting  down- 
ward and  forward,  sawing  the  os  calcis  obliquely,  and 
leaving  a  considerable  portion  in  place  in  the  flap.  The 
lower  ends  of  the  tibia  and  fibula  are  well  exposed  by 
raising  the  anterior  flap  slightly ;  the  sawing  is  begun  ante- 
riorly just  above  the  articular  surface,  and  is  completed  half 
an  inch  above  the  articular  surface  posteriorly.  The  lines  a 
and  b  (Fig.  423)  show  the  sections  made  by  the  saw.  The 
sawn  surface  of  the  os  calcis  is  brought  into  contact  with 
the  sawn  surfaces  of  the  tibia  and  fibula,  and  the  flaps  are 
sutured. 

Amputations  of  the  I^eg. — The  so-called  "  point  of 
election  "  is  at  the  upper  part  of  the  middle  third  of  the  leg. 

^  Operative  Surgery,  by  Joseph  D.  Bryant. 


THE    LEG. 


1049 


Seventy  years  ago  Liston  advised  surgeons  not  to  amputate 
in  the  lower  third  of  the  leg  because  of  the  scantiness  of 
the  soft  parts,  because  the  stump  is  apt  to  ulcerate,  and 
because  it  is  uncomfortable  in  an  artificial  leg.  These  views 
have  been  much  modified.  The  amputation  near  the  ankle 
is  safer  than  the  amputation  near  the  knee,  and  artificial  legs 
are  now  made  which  may  be  worn  with  comfort.  In  ampu- 
tations of  the  leg  by  the  long  anterior  flap,  cut  through  the 
skin,  dissect  up  the  anterior  muscles  with  the  flap,  and  cut 
all  the  posterior  tissues  with  a  single  transverse  sweep. 
Amputation  by  the  rectangular  flap,  Teale's  method,  is  very 
useful  (see  page  1042).  The  long  flap  is  anterior,  and  is  in 
length  and  breadth  equal  to  one-half  the  circumference  of 
the  limb.  The  short  flap  is  one-fourth  the  length  of  the 
long  flap.  The  flaps  are  dissected  up,  the  bones  are  sawn, 
thelong  flap  is  turned  upon  itself,  and  its  edges  are  sutured 
to  the  edges  of  the  short  flap. 


Fig.   424.— Diagrammatic   representation   of   amputation   of    the   leg   after   the   method   of 

Bier. 

Bier  suggests  a  plan  (Fig.  424)  to  increase  the  supporting 
power  of  the  stump  after  a  leg-amputation.  After  the  wound 
has  healed,  a  wedge-shaped  piece  of  bone  is  removed  above 
the  level  of  the  stump.  The  lower  extremity  is  turned  for- 
ward and  upward  through  an  arc  of  90  degrees,  and  unites 
in  this  position  (Zuckerkandl's  Operative  Surgery).  Thus 
the  medullary  cavity  is  closed  and  the  skin  which  must  bear 
pressure  is  healthy  and  free  from  cicatrices;  and  as  the 
muscles  are  still  attached  to  the  bone,  they  do  not  undergo 
atrophy. 

Sedillot's  leg-amputation  (Fig.  425)  is  by  a  long  exter- 
nal flap.  A  longitudinal  incision  is  made  along  the  inner 
edge  of  the  tibia,  the  tissues  are  drawn  toward  the  fibula, 
a  knife  is  introduced  and  passed  to  the  outer  edge  of  the 
tibia,  just  touching  the  fibula,  and  is  brought  out  posteriorly, 


1050 


AMPUTA  TIONS. 


thus  transfixing  the  calf-muscles  and  cutting  an  external  flap. 
A  convex  incision  is  made  on  the  inner  side,  the  bones  are 
cleared  and  are  sawn  one  inch  above  the  flaps,  half  an  inch 
more  being  taken  from  the  fibula  than  from  the  tibia,  and 
the  tibia  being  bevelled  anteriorly. 

Modified  Circular  Amputation  of  the  Leg. — Cut  semi- 
lunar skin-flaps,  lay  them  back,  and  cut  circularly  to  the 
bone  at  the  edge  of  the  turned-up  flap. 
Another  method  of  modified  circular  am- 
putation is  by  adding  to  the  circular  cut  a 
vertical  incision  down  the  front  of  the  leg. 
In  sawing  the  bones  of  the  leg  the  surgeon, 
who  stands  to  the  outer  side  of  the  right 
leg  or  to  the  inner  side  of  the  left  leg, 
divides  the  fibula  first,  and  at  a  higher  level 
than  the  tibia,  and  bevels  the  anterior  sur- 
face of  the  tibia.  In  sawing  the  left  fibula 
the  saw  points  to  the  floor ;  in  sawing  the 
right  fibula  it  points  to  the  ceiling. 

Amputation  of  the  Leg-  by  a  Long- 
Posterior  and  a  Short  Anterior  Flap. — 
In  this  operation  a  posterior  U-shaped  flap 
is  made  equal  in  length  and  breadth  to 
the  diameter  of  the  limb.  The  skin-in- 
cision is  begun  one  inch  below  the  point 
where  the  bone  is  to  be  sawn,  and  behind  the  inner  edge 
of  the  tibia,  and  is  carried  to  a  point  posterior  to  the  peronei 
muscles.  The  gastrocnemius  muscle  is  divided  transversely 
at  the  level  of  the  flap,  the  soft  parts  on  either  side  in 
the  line  of  the  flap  being  cut  to  the  bone.  Through  these 
vertical  cuts  the  muscles  are  lifted 
from  the  bones  and  are  divided 
through  their  lower  part  by  cut- 
ting from  within  outward.  The 
anterior  flap  is  formed  by  making 
a  semilunar  skin-flap  and  by  cut- 
ting the  muscles  across  at  its  re- 
tracted edge  (Fig.  426).  Ainpji- 
tation  of  tlic  leg  by  lateral  flaps  is  not  a  popular  operation,  as 
it  offers  too  much  encouragement  to  subsequent  protrusion 
of  the  bone. 

Bier  endeavors  to  broaden  the  support  after  amputation 
of  the  leg  by  performing  a  cuneiform  osteotomy  and  bend- 
ing the  lower  fragment  to  a  right  angle  with  the  upper,  and 
obtaining  union  of  the  fragments  (Fig.  424). 


Fig.  425. — Sedillot's 
amputation  of  the  leg 
(Wyeth). 


Fig.  426. — Amputation  of  the  leg  by 
a  long  posterior  flap  (Gross). 


THE   LEG. 


105  I 


Amputation  just  below  the  Knee.— The  seat  of  election 
is  one  inch  below  the  tuberosities.  No  muscle  is  needed  ni 
the  flap.  Cut  two  flaps  of  skin,  equal  in  size  and  semilunar 
in  shape  these  flaps  beginning  anteriorly  two  inches  below 
the  tuberosity  of  the  tibia.  One  flap  is  antero-external  and 
the  other  is  postero-internal.  The  flaps  are  pulled  up,  the 
anterior  muscles  are  cut  as  high  up  as  possible,  and  the  pos- 
terior muscles  are  cut  through  the  middle  of  the  portion  ex- 
posed (Bell).  The  bone  is  sawn  one  inch  below  the  tuber- 
osity. •     ,     •       \^     ^u 

Disarticulation  of  the  Knee.— In  disarticulation  by  the 
loner  anterior  flap,  make  a  long  anterior  skin-flap,  incise  the 
licrament  of  the  patella,  turn  up  the  flap  with  the  patella, 
open  the  joint,  and  complete  the  disarticulation  by  cutting 
from  within  outward  and  downward.  The  knee  may  be  dis- 
articulated by  means  of  a  long  anterior  and  a  short  posterior 

flap.  ,   ,  o       ' 

Amputation  through  the  Femoral  Condyles.— ^^5^ 
Method  by  a  Long  Posterior  Flap.— Cd^rry  a  skm-incision,  with 


Fig.  427.— Diagrammatic  representation  of  Gritii's  operation. 


a  very  slight  downward  curve  from  one  condyle  to  the  other, 
across  the  middle  of  the  patella.  Cut  down  to  the  bone, 
retract  the  flap,  and  cut  the  quadriceps  above  the  patella. 
Insert  a  long  knife  at  one  angle  of  the  wound,  pass  it  back 
of  the  femur,  and  make  it  emerge  at  the  opposite  angle,  cut- 
ting a  posterior  flap  eight  inches  long.  Retract  the  posterior 
flap  clear  for  sawing,  and  section  the  condyles  horizontally. 
Carden  made  a  curved  section  of  the  condyles  at  their  widest 
part  In  children  Buchanan  showed  that  we  can  easily  sepa- 
rate the  lower  femoral  epiphysis.  In  Gritti's  supracondyloid 
amputation  an  oblique  incision  is  made.  The  upper  end  of 
the  incision  is  posterior  and  just  above  the  condyles,     its 


1052 


AMPUTA  TIONS. 


lower  end  is  anterior  and  two  fin^^er-breadths  below  the 
patella  (Kocher).  The  ligament  of  the  patella  is  cut,  the 
flap  is  turned  up,  the  femur  is  sawn  at  the  base  of  the 
condyles,  the  articular  face  of  the  patella  is  sawn  off,  and 
the  sawn  patella  is  fastened  to  the  sawn  femur  and  the  flaps 


Fig.  428. — Diagrammatic  representation  of  Sabanejeff's  operation. 


are  sutured  (Fig.  427).  Sabanejeff  makes  an  anterior  flap, 
opens  the  knee-joint  from  behind,  saws  the  condyles  at  their 
broadest  part,  takes  a  bone-flap  from  the  anterior  portion  of 
the  tibia  and  fastens  it  to  the  femur  (Fig.  428). 

Amputation  of  the  Thigh. — In  high  amputation  in  the 
loiver  third  either  a  flap  or  a  circular  operation  may  be  per- 


FiG.  429. — Amputation  of  the  thigh  (Bryant). 


formed.  In  a  douple-flap  operation  a  semilunar  skin-incision 
should  be  made  from  without  inward,  and  the  muscles  should 
be  cut  by  transfixion  (Fig.  429).  In  the  lower  third  Teale's 
flap  or  the  long  anterior  flap  may  be  employed.  The  ampu- 
tation by  a  long  anterior  flap  consists  in  making  a  lengthy 


THE    LEG. 


1053 


skin-flap,  reflecting  it,  cutting  the  anterior  structures  to  the 
bone,  again  entering  the  long  knife  at  one  angle  of  the  incision, 
pushing  it  back  of  the  femur,  bringing  it  out  at  the  other 
angle,  and  cutting  the  structures  behind  the  bone  directly 
backward.  Bell  amputates  by  a  long  anterior  semilunar  flap 
and  a  short  posterior  flap.  In  amputations  in  the  upper  tzi'o- 
tliirds  of  the  thigh  the  best  plan  is  to  mark  out  equal  an- 
terior and  posterior  semilunar  skin-flaps,  divide  the  skin 
with  a  scalpel,  enter  the  long  knife  at  one  angle  of  the  an- 
terior flap,  bring  it  out  at  the  other  angle,  and  cut  the  muscles 


Fig.  430. — Macewen's  method  for  compression  of  the  abdfiminal  anrta  ( Ai'/rrhari  T<^xi-Book 

of  Surgery). 

by  transfixion.  Cut  the  posterior  flap  in  the  same  manner. 
Some  surgeons  prefer  a  long  anterior  semilunar  flap  and  a 
short  posterior  semilunar  flap.  The  pure  circular  amputation 
is  not  adapted  to  the  thigh. 

Disarticulation  at  the  Hip-joint. —  Disarticulation  at  the 
hip-joint  can  be  affected  while  the  circulation  is  controlled 
by  Macewen's  method  of  compression  of  the  aorta  (Fig.  430). 
The  weight  of  the  assistant's  body  is  thrown  upon  the 
patient's  aorta  by  the  right  fist,  placed  slighth-  to  the  left  of 
the  umbilicus.  McBurney  has  suggested  the  prevention  of 
bleeding  by  making  a  small  abdominal  incision  and  having  an 


1054 


AM  PUT  A  TrONS. 


assistant  make  direct  digital  pressure  upon  the  iliac  artery. 
I  employed  McBurney's  method  in  a  recent  case  and  found  it 
most  satisfactory.  In  the  bloodless  method  of  Wyeth  (Figs. 
431,  432)  the  band  of  the  Esmarch  apparatus  is  held  up  by 
Wyeth's  pins,  the  outer  pin  being  inserted  one  and  a  half 
inches  below  and  a  little  internal  to  the  anterior  superior 
spine  of  the  ilium,  and  brought  out  just  back  of  the  great 
trochanter.  The  inner  pin  is  entered  one  inch  below  the 
level  of  the  crotch,  and  internal  to  the  saphenous  opening, 
and  it  emerges  one  and  a  half  inches  in  front  of  the  tuber- 
osity of  the  ischium.  The  hip  is  brought  well  over  the  edge 
of  the  table,  a  circular  incision  is  made  down  to  the  deep 
fascia  six  inches  below  the  constricting  band,  and  is  joined  by 
a  longitudinal  skin-cut  reaching  from  the  band  to  the  level 


Fig.  431. — Amputation  at  the  hip-joint :   Wyeth's  bloodless  method. 


of  the  circular  incision,  and  the  cuff  is  reflected  to  the  level 
of  the  lesser  trochanter.  The  muscles  are  cut  by  a  circular 
sweep  at  the  level  of  the  retracted  cuff,  the  capsule  is  opened 
freely,  the  cotyloid  ligament  is  cut  posteriorly,  the  thigh  is 
bent  upward,  forward,  and  inward  to  dislocate  the  head  of 
the  bone,  and,  using  the  thigh  as  a  handle,  the  round  hga- 
ment  is  incised  and  the  limb  removed.  After  ligating  the 
vessels  and  introducing  tubes  the  flaps  are  sewn  together  ver- 
tically. The  old  transfixion  operation  is  practically  extinct. 
A  ~[ -amputation  may  be  employed.  It  consists  of  an  external 
straight  incision  down  to  the  bone,  starting  over  the  great 
trochanter,  down  the  outer  side  of  the  limb,  and  a  circular 
incision  through  the  skin  five  inches  below  the  constricting 
band,  the  muscles  being  cut  by  a  circular  sweep  at  the  level 


THE    LEG. 


lO 


DO 


of  the  retracted  skin.  Tliis  method  affords  easy  access  to 
the  joint.  The  bloodless  method  of  Wyeth,  as  applied  to 
the  hip-joints  and  shoulder-joints,  is  one  of  the  notable 
modern  advances  in  the  art  of  surgery.     Larrey  amputated 


Fig.  432. — Wyeth's  bloodless  amputation  at  the  hip  joint  cuff  of  skin  and  subcutaneous 
fat  turned  back,  muscles  divided  at  level  of  small  trochanter,  bone  partly  stripped,  and  large 
vessels  exposed  for  deligation. 

by  lateral  flaps,  and  Liston  by  anteroposterior  flaps.  For- 
neaux  Jordan's  method  consists  in  dividing  the  soft  parts 
low  down,  tying  the  bloodvessels  on  the  face  of  the  stump, 
shelling  out  the  femur  from  the  soft  parts,  and  disarticulating. 


XXXVIII.  DISEASES   OF   THE    BREAST. 

Mammillitis  and  Fissure. — The  nipple  may  inflame 
as  a  result  of  injur}-,  but  the  condition  is  rarely  encoun- 
tered except  in  a  woman  Avho  is  nursing  a  baby.  It  is  most 
common  after  a  first  pregnancy,  when  the  nipple  is  deformed 
or  when  the  skin  is  delicate.  The  nipple  is  slightly  injured 
during  nursing,  and  the  epithelium  is  macerated  by  the  milk 
and  saliva.  If  the  inflammation  is  not  arrested,  an  area  ex- 
coriates or  an  irritable  ulcer  forms  (a  fissure).     This  fissure 


1056  DISEASES    OF   THE   BKEAS1\ 

is  often  surrounded  by  an  area  of  acute  inflammation,  and 
nursing  causes  intense  agony.  Because  of  the  pain  the 
mother  is  apt  to  extend  the  intervals  between  nursing,  and 
as  a  consequence  the  breasts  become  swollen  with  retained 
milk.  The  ulcer  not  unusually  bleeds  when  taken  by  the 
child.  Besides  the  fact  that  a  fissure  causes  pain  to  the 
mother,  it  often  leads  to  grave  trouble.  It  is  a  suppurating 
area,  and  as  such  may  lead  to  abscess  of  the  mother's 
breast,  or  may  impair  the  health  of  the  nursing  child. 

Prevention  of  Fissure. — During  pregnancy  the  nipples 
should  be  carefully  attended  to.  They  should  be  washed 
often  in  sterile  water  and  bathed  in  alcohol,  and  if  retracted 
ought  to  be  drawn  out  repeatedly.  During  lactation  the 
nipples  are  washed  in  sterile  water,  dried,  and  dusted  with 
borated  talc  powder  as  soon  as  an  act  of  nursing  is  com- 
pleted. Washing  the  nipples  regularly  Avith  the  following 
solution  tends  to  prevent  the  formation  of  a  fissure :  iodid 
of  mercuiy,  gr.  ij ;  alcohol,  §jss ;  glycerin  and  distilled 
water,  act  a  pint  (Lepage).  If  a  small  abrasion  appears, 
order  the  woman  to  wear  a  nipple-shield  during  nursing, 
and  after  each  act  of  nursing  to  wash  the  part  with  hot 
sterile  water,  dry,  and  dust  borated  talc  over  the  surface.  If 
a  fissure  forms,  wean  the  child  at  once,  and  dry  up  the  milk 
in  both  breasts.  It  is  useless  to  try  to  diy  it  up  in  one 
breast.  Milk  may  be  dried  up  by  applying  ointment  of  bella- 
donna locally  and  administering  iodid  of  potassium  inter- 
nally; by  strapping  the  breasts  with  adhesive  plaster  (Parker); 
or  by  applying  to  the  nipples  six  times  a  day  a  5  per  cent,  so- 
lution of  cocain  in  equal  parts  of  glycerin  and  water  (Joise). 
The  fissure  is  not  treated  by  ointments.  These  preparations 
are  septic,  prevent  drainage,  and  aggravate  maceration.  Wash 
the  fissure  twice  a  day  with  peroxid  of  hydrogen,  dress  it  with 
gauze  wet  in  boric-acid  solution  (gr.  x  to  sj  of  water),  and 
cover  the  dressing  with  waxed  paper.  If  the  fissure  resists 
treatment,  touch  it  with  lunar  caustic. 

Acute  Mastitis  and  Abscess. — Ax^iJtejiiflammation  of 
the  breast,  as  a  result  of  injury  of  the  breast  or  nipple,  may 
occur  in  either  sex  at  any  time  of  life^  Very^commonlyTn 
both  sexes  a  few  days  after  birth  the  bFeast-becomes . di.s- 
tended  with  a  material  .which  iri  reality  Ls  milk.  The  fluid 
is  usually  small  in  quantity.  The  process  is  physiological, 
and,  as  a  rule,  ceases  spontaneously  (Guelliot).  If  it  lingers, 
the  application  of  belladonna  ointment  will  stop  secretion. 
If  the  nurse  meddles  with  and  tries  to  squeeze  out  the  fluid, 
acute  mastitis  is  apt  to  arise  in  one  gland,  or  occasionally  in 


ACUTE   ^fASTIT/S  .1 XD   ABSCESS.  IO57 

both.  The  skin  of  the  breast  reddens,  the  gland  swells  and 
becomes  tender  and  painful,  the  child  loses  its  appetite  and 
becomes  feverish,  restless,  and  sleepless.  Such  a  condition 
is  treated  by  the  local  use  of  lead-water  and  laudanum.  If 
pus  forms,  the  local  signs  and  constitutional  symptoms  are 
aggravated.  Evacuate  the  pus,  dress  witli- hot.  antiseptic 
fomentations,  and  be  sure  that  the  child  is  well  nourished. 
Tonics  and  stimulants  are  indicated. 

A  condition  identical  with  the  secretory  activity  of  the 
glands  of  the  new-born  may  occur  in  either  sex  at  puberty. 
The  methods  of  treatment  are  the  same  in  both  cases.  As  a 
matter  of  fact,  rarely  more  than  one  lobule  at  this  period  in- 
flames, and  suppuration  is  most  unusual. 

Mastitis  is  most  usually  met  with  in  a  woman  who  is  nurs- 
ing a  child,  and  is  due  to  bacterial  infection.  Primipara  are 
particularly  liable  to  develop  mastitis.  So  are  women  with 
deformed  nipples.  In  many  cases  an  abrasion  of  the  nipple 
exists,  and  through  this  breach  of  continuity  organisms  gain 
entrance  to  the  breast-tissue.  The  abrasion  may  be  so  slight 
that  it  can  only  be  detected  when  the  nipple  is  examined 
through  a  magnifying-glass  (Marmaduke  Shield).  Strepto- 
coccic infections  are  very  generally  due  to  inoculation  of  a 
fissure  of  the  nipple.  Organisms  may  pass  up  the  milk-ducts, 
coagulating  the  milk  and  penetrating  through  the  walls  of 
the  acini.  Staphylococci  usually  adopt  this  route  in  reaching 
the  breast-tissue.  Occasionally  causative  organisms  reach 
the  breast  through  the  arteries  (in  septicemia  and  in  septic 
wounds  of  the  genital  organs). 

Symptoms. — There  are  pain,  swelling,  and  tenderness  in 
the  breast,  and  in  most  cases  a  fissure  or  abrasion  exists. 
There  is  a  febrile  condition.  Occasionally  a  chill  ushers  in 
the  attack. 

Treatment. — Stop  nursing.  Arrest  the  secretion  of  milk. 
Treat  the  nipple  as  advised  on  page  1056.  Support  the 
breast  and  apply  ichthyol  ointment  or  lead-water  and  laud- 
anum. 

A  mastitis  may  undergo  resolution  ;  it  may  terminate  in  or- 
ganization and  induration  ;  it  may  e\-entuate  in  suppuration. 

Acute  abscess  of  the  breast  follows  an  acute  mastitis. 
There  may  be  but  one  area  of  suppuration,  or  multiple  foci 
may  exist,  which  eventually  fuse.  The  symptoms  of  mas- 
titis, local  and  constitutional,  are  greatly  aggravated.  After 
a  time  the  skin  becomes  dusky  and  edematous.  The  axillary 
and  superficial  cervical  glands  enlarge.  The  abscess  will 
eventually  open  spontaneously  at  one  or  more  points,  leaving 
67 


1058  DISEASES    OF   THE   BREAST. 

branching  fistulse.  A  superficial  abscess  is  situated  just 
beneath  the  nipple,  and  pus  may  flow  from  the  nipple. 

An  intramammary  abscess  is  in  the  depths  of  the  gland. 
There  are  often  multiple  foci  of  suppuration.  Nodules  are 
felt  in  the  gland,  pus  may  run  from  the  nipple,  but  cutaneous 
redness  is  late  in  appearing. 

Retromammary  abscess  is  a  rather  rare  condition.  It  may 
occur  alone  or  be  associated  and  connected  with  an  area  of 
intramammary  suppuration.  This  condition  may  result  from 
metastasis  or  from  caries  of  a  rib.  The  breast  is  lifted  up 
by  the  fluid  beneath  it. 

Treatment. — Open  a  superficial  abscess  by  an  incision 
radiating  from  the  nipple.  Treat  as  any  other  acute 
abscess.  An  intramammary  abscess  should  be  opened 
by  a  radiating  incision,  and  pockets  of  pus  should  be  broken 
into  with  the  'finger.  An  examination  is  made  to  determine 
if  a  retromammaiy  abscess  also  exists.  If  this  is  found  to 
be  the  case,  an  incision  is  made  at  the  point  of  junction  of 
the  thorax  and  mammar}^  gland,  and  at  the  lower  border 
of  the  gland.  The  gland  is  raised  from  the  chest-wall,  the 
pus  evacuated,  and  a  drainage-tube  is  inserted.  If  retro- 
mammary abscess  exists  alone,  make  the  last-named  incision 
in  the  first  place. 

Chronic  Mastitis. — This  condition  may  be  present  in 
only  a  portion  of  the  breast,  or  may  attack  many  lobules 
(lobular  mastitis).  The  ordinary  form  may  arise  after  weaning 
a  child,  or  may  be  due  to  a  blow,  to  the  pressure  of  corsets, 
or  to  numerous  slight  traumatisms.  It  may  occur  in  the 
young,  the  middle  aged,  or  the  old.  The  patient  has  slight 
pain  at  times  in  the  gland.  Examination  detects  a  firm, 
elastic  area,  which  is  somewhat  tender  and  does  not  present 
distinct  edges.  The  skin  is  not  adherent  to  the  mass  unless 
suppuration  occurs.  If  the  mass  is  pressed  against  the  chest 
by  the  surgeon's  fingers,  it  becomes  evident  that  no  real 
tumor  exists. 

Treatment. — Remove  any  cause  of  irritation.  Support 
the  breast  in  a  sling.  Apply  ichthyol  ointment.  During 
the  night  employ  a  hot-water  bag.  If  pus  forms,  treat 
as  before  directed. 

Chronic  lobular  mastitis  is  a  condition  in  which 
numerous  lobules  become  indurated.  The  real  cause  of 
this  condition  is  unknown.  It  may  occur  at  any  age  after 
puberty,  and  often  attacks  both  breasts.  Such  a  breast 
is  apt  to  be  painful,  especially  at  the  menstrual  periods ;  it 
feels  unnatural,  solid,  and  careful  examination  detects  numer- 


TCMOMS   OF   TIIK    MAMMARY  GI.AXD.  IO59 

ous  indurated  areas,  each  of  which  is  of  small  size.  At 
the  menstrual  period  the  breast  enlarges  and  new  nodules 
may  be  detected.  In  some  of  these  cases  violent  neuralgic 
l^ims^r^  present  in  the  gland  (mastod}-nia).  Chronic  lobular 
mastitis  is  apt  to  lead  to  cyst-formation.  When  c\-sts  form 
fluid  may  occasionalh'  discharge  from  the  nipple. 

Treatment. — Support  the  breast  and  apply  ichthyol_oint- 
ment  or  belladonna  ointment.  Examine  the  generative  organs 
and  correct  any^"xisting  abnormalit}'.  Improve  the  general 
health  by  good  food,  tonics,  and  open-air  life.  In  cases 
^wTiere  multiple  cysts  are  known  to  exist  the  question  of 
treatment  is  uncertain.  Tkere-  seems  to  be  no  doubt  that 
such  cases  tend  in  some  instances  to  eventuate  in  cancer,  ^^'e 
believe  that  the  proper  treatment  is  extirpation  of  the  breast. 

Tuberculosis  of  the  Mammary  Gland. — (See  page 

13;-) 

Cysts  and  Tumors  of  the  Nipple  and  the  Mam- 
mary Gland. — Tuniors  are  rare  in  the  nipple,  but  do  some- 
times occur.  The  following  growths  are  occasionally  seen : 
fibroma,  angeioma,  papilloma,  myxoma,  myoma,  and  epithe- 
lioma. Sebaceous  cysts  of  the  nipple  and  areola  are  not  very 
unusual.  A  cancer  of  the  nipple  may  be  a  primar}-  groAvth.  or 
may  be  secondary'  to  gland  cancer.  Primar}-  epithelioma  of 
the  nipple  presents  the  same  general  characters  as  epithelioma 
in  any  other  region.  It  begins  as  an  indurated  area  in  the 
areola,  or  an  excoriation  of  the  nipple.  Ulceration  soon 
occurs.  The  ulcer  is  irregular  in  outline,  has  hard  edges,  fur- 
nishes a  foul  red  flow,  and  the  discharge  is  sanious  and  fetid. 
The  mammar}^  gland  becomes  infiltrated  at  an  early  period. 
The  subclavian  glands  enlarge,  and  later  the  axillan.-  glands. 
This  growth  must  not  be  confounded  with  a  chancre  of  the 
nipple. 

Trcatincnt  of  Tumors  of  the  Xipplc. — Innocent  tumors  are 
to  be  excised  and  the  breast  need  not  be  removed. 

Epithelioma  of  the  nipple  requires  the  complete  extirpa- 
tion of  the  breast,  and  also  the  clearing  out  of  the  lymphatic 
contents  of  the  axilla,  and  possibly  of  the  subclavian  triangle. 

Paget' s  Disease  of  the  Nipple  (Mahgnant  Derma- 
titis ). — This  condition  is  a  chronic  inflammation  of  the 
epithelial  layer  of  the  nipple  and  areola  occurring  in  women 
beyond  middle  life,  and  is  a  not  unusual  precursor  of  epi- 
thehoma  of  the  nipple  and  of  duct  cancer.  Paget's  disease 
is  not  a  simple  eczema,  it  is  not  associated  with  the  usual 
causes  and  attendants  of  eczema  either  local  or  constitu- 
tional, and  is  not  cured  by  remedies  which  control  the 
ordinarv  disease. 


I060  DISEASES    OF   THE   BREAST. 

The  diseased  area  is  raw  and  red,  and  from  it  exudes 
copiously  a  thick,  yellow  discharge.  In  some  cases  Pagct's 
disease  is  secondary  to  duct  cancer,  auto-infection  of  the 
nipple  having  been  effected  by  the  fluid  flowing  from  the 
ducts.  Investigations  have  shown  the  presence  of  psoro- 
sperms  in  an  area  of  Paget's  disease. 

Treatment  consists  of  removal  of  the  entire  breast  and 
clearing  out  of  the  axilla  and  subclavian  triangle. 

Tumors  of  the  Mammary  Gland. — These  tumors 
may  be  innocent  or  malignant.     The  innocent  tumors  are 

Pibro-adenomata  or  Cystic  Adenomata,  Myxomata, 
Villous  Papillomata,  and  Angiomata. — It  is  maintained 
by  most  authorities  that  any  innocent  tumor  of  the  gland 
may  and  often   does  become  malignant. 

Fibro-adenoma. — The  nomenclature  of  these  growths 
is  in  a  state  of  great  confusion.  The  name  of  fibro-aden- 
oma was  given  by  Cornil  and  Ranvier  to  the  same  sort  of 
growth  which  the  younger  Gross  called  a  fibroma,  Billroth 
an  adeno-fibroma,  and  Sir  Astley  Cooper  a  chronic  mam- 
mary tumor.  It  is  doubtful  if  a  pure  fibroma  ever  occurs 
in  the  mammary  gland  (Senn).  A  fibro-adenoma  consists 
of  acini  surrounded  by  fibrous  tissue.  Each  of  these 
structures  proliferates,  but  the  fibrous  tissue  does  so 
much  more  rapidly  than  the  glandular.  A  growth  of  this 
character  is  surrounded  by  a  capsule,  and  is  movable.  It 
is  firm,  elastic,  lobulated,  superficially  situated,  and  of  slow 
growtE'  It  is  unassociated  with  retracted  nipple,  glandular 
enlargement,  adheslbh  to  the'^kin,  or  cachexia,  and  may 
occur  at  any  age  up  to  fifty,  but  is  most  common  between 
twenty  and  thirty  (J.  Bland  Sutton).  Such  a  tumor  is  rarely 
very  painful,  but  it  may  be  tender  on  rough  handling  and 
may  be  painful  at  the  menstrual  period.  As  a  rule,  there  is 
but  one  of  these  tumors  in  a  mammary  gland,  but  one  may 
exist  in  each  gland. 

Treatment. — Extirpation  of  the  tumor. 

Cystic  adenoma  (adenocele)  is  a  rare  form  of  slowly- 
growing  tumor,  which  is  apt  to  grow  to  a  large  size,  which 
is  nodular  in  outline,  hard  to  the  touch,  and  firmly  attached 
to  the  breast,  but  mobile  upon  the  chest.  A  cystic  adenoma  • 
has  a  distinct  capsule.  This  form  of  tumor  is  painless,  and 
is  most  apt  to  occur  in  women  between  thirty  and  forty 
who  have  born  children.  The  growth  is  adherent  to  the 
skin,  but  the  cutaneous  surface  is  not  discolored,  the  cuta- 
neous veins  are  not  distended,  the  axillary  glands  are  not 
enlarged,  and  the  nipple  is  not  retracted.     From  the  walls 


CYSTS   OF   THE    ^rA^r^[ARy   GLAXD.  I061 

of  the  dilated  acini  papillomatous  growths  are  apt  to  arise 
(intracystic  vegetations ). 

Trcalniciit. — Removal  of  the  breast. 

Myxoma  is  a  rare  tumor,  and  only  occurs  in  a  person  of 
middle  age.  The  growth  is  solitar}-,  is  soft,  ma}-  be  round 
or  lobulated,  and  occasionally  fungates.  The  nipple  is  not 
retracted,  the  superficial  veins  are  not  distended,  and  the 
axillar}'  glands  are  not  enlarged. 

Trcatuioit. — Removal  of  the  mammar)'  gland. 

Angioma. — This  form  of  tumor  is  veiy  rare.  It  may 
arise  secondarily  to  a  nevus  of  the  skin  (Sutton).  The 
diagnosis  of  angioma  of  the  skin  is  readily  made.  In 
a  cavernous  angioma  of  the  breast  it  will  be  found  that 
the  tumor  can  be  lessened  in  size  by  pressure,  and  will  be 
increased  in  size  by  coughing,  laughing,  and  holding  the 
breath.  Pulsation  ma\-  be  detected  and  a  bruit  may  be 
audible. 

Treatment. — For  treatment  of  nevus  see  page  283.  If  a 
cavernous  angioma  exists  in  the  mammar}'  gland,  it  will  be 
necessary  to  extirpate  the  gland. 

Cysts  of  the  Mammary  Gland. — Involution  cysts 
(cystic  degeneration  of  the  mamma)  occur  in  women 
who  are  approaching  the  menopause.  They  occur  earlier 
in  those  who  are  sterile  than  in  those  who  have  born  chil- 
dren, and  may  arise  after  chronic  mastitis.  The  paren- 
chyma of  the  gland  undergoes  atrophic  change,  but  the 
ducts  remain,  become  blocked  and  dilated.  Numerous 
small  cysts  form,  and  both  glands,  as  a  rule,  suffer.  Villous 
growths  may  arise  in  the  walls  of  the  ducts.  In  some  cases 
there  is  much  white  fibrous  tissue  between  the  cysts  (cystic 
fibroma). 

The  subjects  of  this  disease  are  often  nervous,  hysterical, 
and  despondent.  One  or  more  ill-defined  indurations  are 
detected.  Frequently  there  is  a  history  of  discharge  from 
the  nipple  and  of  attacks  of  lancinating  pain  in  the  breast. 
Cystic  breasts  are  dangerous,  because  the  intrac}^stic  vege- 
tations are  liable  to  eventuate  in  duct  cancer. 

Treatvwnt. — In  such  cases,  after  confirming  the  diagnosis 
by  an  exploratoiy  incision,  remove  the  entire  breast  (Snow). 

Lacteal  cyst  (galactocele)  is  an  accumulation  of  milk 
brought  about  by  blocking  of  some  of  the  milk-ducts.  It 
arises  soon  after  the  deliveiy  of  the  child,  and  grows  rapidly. 
A  large  quantit}'  of  milk  may  collect,  and  rupture  of  the 
cyst-walls  can  occur,  the  fluid  passing  into  the  glandular 
connecti\'e  tissue. 


I062  DISEASES    OE   THE   BREAST. 

A  galactocele  is  rounded,  fluctuates  distinctly,  and  increases 
in  size  during  nursing.  There  is  little  or  no  pain.  In 
some  cases  the  contents  of  the  cyst  coagulate  and  a  solid 
mass  is  formed. 

Treatment. — Incision  and  drainage. 

Hydatid  cysts  are  rare,  but  do  occasionally  occur. 

Treatment. — Excision. 

Malignant  tumors  of  the  mammary  gland  are  ten 
times  more  common  than  innocent  tumors. 

Sarcoma. — Sarcoma  of  the  mammary  gland  is  a  very  rare 
growth  (less  than  lo  per  cent,  of  breast  tumors).  It  may  occur 
at  any  age  from  pubert}'  to  old  age,  but  is  most  common  from 
twenty  to  thirty-five.  The  growth  may  be  composed  of  round 
cells  or  spindle  cells,  both  varieties  may  be  present,  and 
myeloid  cells  may  be  found.  Circumscribed  sarcoma  arises 
usually  between  the  ages  of  twenty  and  thirty ;  it  is  firm  to  the 
touch,  as  it  contains  much  fibrous  tissue,  is  painless,  does  not 
grow  very  rapidly,  glands  are  not  involved,  and  there  is  no 
cachexia.  The  nipple  is  not  retracted.  The  growth  may 
adhere  to  the  skin.  It  is  composed  of  giant-cells  or  spindle- 
cells,  and  rarely  returns  after  extirpation  of  the  breast. 

Diffused  sarcoma  is  composed  of  small  round  cells, 
arises  in  the  center  of  the  breast,  and  grows  with  great 
rapidity.  It  is  most  commonly  met  with  about  the  age  of 
thirty-five,  and  a  history  of  injury  can  often  be  elicited.  The 
tumor  is  soft,  some  parts  being  softer  than  others  because 
of  cyst-formation.  It  is  usually  mobile  upon  the  thorax, 
though  it  soon  becomes  adherent  to  the  skin.  The  tumor 
reaches  a  very  great  size,  and  soon  fungates  through  the 
skin.  There  is  little  or  no  pain.  The  cutaneous  veins  over 
the  tumor  are  distended,  the  nipple  is  not  retracted,  and  the 
axillary  glands  are  not  often  enlarged.  Diffuse  sarcoma  is 
apt  to  recur  after  removal. 

Treatment. — Remove  the  breast,  and  if  the  muscles  of  the 
chest-wall  are  infiltrated,  remove  them.  The  axillary  glands 
are  removed  if  they  are  enlarged,  but  not  otherwise.  Opera- 
tion will  not  cure  when  metastases  exist.  If  the  case  is  in- 
operable, we  can  try  the  use  of  Coley's  fluid.  If  the  toxins 
of  erysipelas  fail  to  arrest  the  progress  of  the  disease,  keep 
the  patient  as  comfortable  as  possible  by  the  administration 
of  cocain  and  morphin. 

Carcinoma  or  Cancer  of  the  Mammary  Gland. — The 
great  majority  of  mammary  tumors  belong  to  the  genus 
carcinoma.  Cancer  is  due  to  proliferation  of  the  epithelium 
of  the  acini  (acinous  cancer)  or  of  the  ducts  (duct  cancer). 


TC'J/OA'S    OF   THE   MAMMARY   CLAXD.  I063 

Acinous  cancer  is  vastly  commoner  than  duct  cancer. 
Usually  there  is  much  connective  tissue  and  but  little 
parenclu'ma  in  the  growth  (scirrhus  cancer).  In  some 
cases  there  is  little  connective  tissue  and  much  parenchyma 
(encephaloid  or  medullary  cancer).  If  colloid  degeneration 
of  the  parenchyma  or  stroma  occurs,  the  growth  is  spoken 
of  as  colloid  cancer. 

Scirrhus,  the  common  form  of  acinous  cancer,  is  almost  as 
hard  as  stone.  On  section  it  is  concave,  and  Sutton  sa}'s 
"  resembles  an  unripe  pear."  The  tumor  is  without  a  cap- 
sule, and  the  epithelial  cells  are  surrounded  by  masses  of 
fibrous  tissue.  Portions  of  tissue,  even  some  distance  away 
from  the  tumor,  contain  foci  of  proliferating  embryonic  epi- 
thelial cells.  In  atrophic  or  withering  scirrhus  the  fibrous 
stroma  contracts  and  epithelial  cells  undergo  fatt}'  degenera- 
tion (Senn). 

Causes  and  Symptoms. — Scirrhus  is  more  common  among 
women  who  have  born  children  than  among  those  who  have 
not.  Heredity  is  manifest  in  only  about  10  per  cent,  of  cases 
(Bryant).  The  younger  Gross  found  it  in  one  case  out  of 
nine.  Trauma  has  no  apparent  influence  in  producing  can- 
cer. The  disease  is  rare  before  the  age  of  thirty-five,  and 
is  most  common  between  forty-five  and  fifty.  The  author 
operated  for  scirrhus  of  the  breast  on  a  woman  only 
twenty-seven  years  of  age.  Henry  saw  a  woman  of 
twenty-one  with  cancer.  It  is  frequently  met  with  in 
the  aged.  These  tumors  are  rare  in  the  negro  race. 
A  hard  nodule  is  found  in  the  breast,  usually  under  the 
nipple,  but  possibly  far  away  from  it.  The  growth  is  nod- 
ular, and  is  immobile  from  the  beginning.  In  a  large,  fat 
breast  there  is  often  a  deceptive  sense  of  mobility,  because 
some  of  the  breast-tissue  moves  with  the  tumor.  The  cancer 
may  have  been  present  for  a  considerable  time  before  being 
discovered.  In  obscure  lesions  of  bones  and  viscera  examine 
the  mammary  glands,  because  the  trouble  might  be  due  to 
metastasis  from  an  undiscovered  carcinoma  of  the  breast. 
Retraction  of  the  nipple  is  present  in  over  one-half  of  the 
cases  (S.  \V.  Gross).  It  occurs  when  the  growth  is  near  the 
nipple,  and  is  due  to  the  contracting  fibrous  tissues  of  the 
tumor  pulling  on  the  milk-ducts.  If  the  growth  is  far  away 
from  the  nipple,  a  dimple  is  apt  to  form  on  the  skin  of  the 
breast  because  of  the  pulling  upon  the  suspensory  fibers. 

Glandular  enlargement  in  the  axilla  soon  follows  the  ap- 
pearance of  a  scirrhus  ;  the  glands  become  very  hard  and 
adherent.     In  over  60  per  cent,  of  persons  the  glands  of  the 


1064  DISEASES    OE   THE   BREAST. 

axilla  are  felt  to  be  enlarged  when  the  patient  first  comes  for 
treatment.  Because  the  surgeon  cannot  feel  enlarged  glands  is 
no  proof  that  there  are  none.  As  a  matter  of  fact,  the  glands 
are  usually  involved  within  two  months  of  the  beginning  of 
the  disease,  but  the  involvement  can  rarely  be  detected  ex- 
ternally until  months  later.  Enlargement  of  the  axillaiy 
glands  is  followed  by  enlargement  of  the  glands  in  the  po.s- 
terior  cervical  triangle  and  in  the  mediastinum.  Herbert 
Snow  has  shown  that  the  blocking  of  the  axillary  glands 
often  leads  to  regurgitation  of  lymph  containing  cancer-cells, 
the  cells  being  thus  deposited  in  the  head  of  the  humerus 
and  the  thymus  gland.  Cells  in  the  thymus,  after  a  time, 
cause  a  projection  of  the  sternum  (the  sternal  symptom). 
When  the  axillary  lymphatics  are  extensively  involved  the 
arm  swells  from  obstruction  to  the  lymph-flow  (lymph 
edema)  or  pressure  upon  the  vein.  The  tumor  usually 
grows  rather  slowly  unless  lactation  is  established,  then  it 
grows  rapidly.  As  it  grows  it  infiltrates  adjacent  structures 
(the  pectoral  fascia,  pectoral  muscles,  subcutaneous  cellular 
tissue,  and  skin).  WJhen  the  skin  is  destroyed  an  ulcer  forms, 
and  around  this  ulcer  the  skin  becomes  red  and  filled  with 
cancerous  nodules,  which  feel  like  shot  in  the  skin.  Metas- 
tases are  apt  to  occur  into  the  bones,  liver,  brain,  pleura, 
spine,  thymus  gland,  and  rarely  the  eye. 

Pain  is  usually  present  in  scirrhus  carcinoma.  It  is  lan- 
cinating and  neuralgic  in  character,  and  not  brought  on  or 
increased  by  handling.  It  ceases  if  colloid  degeneration  be- 
gins. The  general  health  is  usually  unimpaired  until  ulcer- 
ation takes  place,  when  cachexia  arises.  The  cancer  en  cui- 
rasse  of  Velpeau  is  a  condition  in  which  the  lymphatic  vessels 
of  the  skin  are  extensively  invaded,  the  growth  itself  being 
adherent  to  the  wall  of  the  thorax.  In  this  condition  the 
chest-wall  is  fixed,  respiration  is  difficult,  and  the  temperature 
is  commonly  somewhat  elevated. 

In  atrophic  or  withering  scirrlius  the  contraction  is  so 
great  that  it  seems  as  though  the  mammary  gland  had 
been  removed.  The  duration  of  scirrhus,  when  left  to  run 
its  course,  varies,  but  the  disease  generally  produces  death 
within  two  and  a  half  years.  Occasionally  it  causes  death 
within  a  year.  In  atrophic  scirrhus  the  patient  may  live  for 
many  years. 

Duct  cancer  is  not  a  common  growth.  It  arises  from  the 
duct-walls  in  conditions  of  cystic  degeneration  of  the  mam- 
mary gland.  The  tumor  is  softer  than  the  acinous  growth, 
and  is  not  nodular.     There  is  no  pain,  no  retraction  of  the 


TUMORS    OF   THE   MAMMARY   GLAXD.  IO65 

nipple,  no  skin  dimple.  Serous  or  bloody  fluid  may  often  be 
squeezed  from  the  nipple.  A  duct  cancer  grows,  infiltrates 
slowly,  and  involves  adjacent  glands  later  than  does  scirrhus. 
Treatment  of  Carcinoma  of  the  Mammary  Gland. — The 
treatment  is  early  and  thorough  operation,  the  earlier  and 
the  more  thorough  the  better.  The  older  surgeons  oper- 
ated simply  to  prolong  life  a  few  months ;  the  modern 
surgeon  operates  with  the  hope  of  curing  the  patient.  In 
1878,  Billroth's  statistics  showed  only  8  cures  in  143 
cases'.  In  1896,  W.  Watson  Cheyne  reported  12  cures  out 
of  21  cases  (57  per  cent.).  The  operation  should  remove 
the  breast  and  much  of  the  skin  above  it,  the  pectoral  fascia, 
and  often  the  pectoral  muscles ;  the  fat  and  glands  of  the 
axilla,  and  sometimes  the  fat  and  glands  of  the  subclavian 
triangle.  If  three  years  after  an  operation  there  has  been  no 
return,  we  regard  the  case  as  cured  (Volkmann's  limit).  Cer- 
tain cases  are  unsuited  for  a  radical  operation  :  cases  in  which 
metastases  exist ;  cases  of  cancer  en  cuirasse ;  cases  where 
axillary  involvement  is  very  great.  Cheyne  would  also  rule 
out  cases  where  large  glands  may  be  felt  above  the  clavicle, 
believing  that  in  such  cases  the  mediastinal  glands  must  be 
cancerous.^ 

HalstecVs  Operation.— Yi^X^.'i.&A  performs  a  very  radical 
operation.  He  removes  suspected  tissue  in  one  piece,  and 
thus  prevents  carcinoma  cells  falling  in  the  wound,  for  it  is 
well  known  that  if  such  cells  should  fall  into  the  wound  they 
may  grow  just  as  may  a  graft  of  healthy  epithelium.  The 
neck,  shoulder,  the  arm  to  the  elbow,  the  entire  surface  of 
the  chest  down  to  the  waist,  the  breast  itself,  the  axilla,  the 
side  and  the  back  must  be  sterilized.  It  is  necessary  to  have, 
besides  scalpels,  and  the  ordinary  instruments  for  an  opera- 
tion, a  great  number  of  hemostatic  forceps  (80  to  lOO).  Place 
the  'pattent  recumbent,  with  a  sand-pillow  under  the  shoul- 
der of  the  affected  side.  The  shoulder  is  right  at  the  edge 
of  the  bed,  and  a  nurse  holds  the  arm  from  the  side.  Hal- 
sted  describes  his  operation  as  follows  i^  The  skin  incis- 
ion is  made  as  shown  in  Fig.  433,  and  is  carried  at  once 
through  the  fat.  The  triangular  skin  flap  {a,  b,  r,)  is  turned 
down.  The  costal  insertions  of  the  great  pectoral  muscle 
and  the  muscle  are  split  between  the  clavicular  and  costal 
portions  and  up  to  a  point  on  the  clavicle  opposite  to  the 
scalene  tubercle,  and  at  this  point  the  clavicular  portion  of 
the  muscle  and  the  tissue  overlying  it  are  cut  through  close 

1  See  Objects  and  Limits  of  Operation  for  Cancer,  by  W.  Watson  Cheyne. 
'^  Johns  Hopkins  Hosp.  Reports,  vol.  iv.;  Annals  of  Sur^.,  Nov.,  1894. 


I066  DISEASES   OE   THE   BREAST. 

to  the  clavicle,  and  the  apex  of  the  axilla  is  at  once  exposed. 
The  cellular  tissue  under  the  clavicular  portion  of  the  muscle 
is  dissected  from  the  muscle,  and  the  splitting  of  the  muscle 
is  continued  on  to  the  humerus.  The  part  of  the  muscle  to 
be  removed  is  cut  through  close  to  its  humeral  insertion. 
The  whole  mass  circumscribed  by  the  first  incision  (skin, 
breast,  areolar  tissue,  and  fat)  is  raised  with  considerable  force 
in  order  to  put  the  submuscular  fascia  on  the  stretch  as  it  is 
stripped  frcftn  the  thorax  close  to  the  ribs.  It  is  well  to  in- 
clude the  delicate  sheath  of  the  pectoralis  minor  muscle. 
The  lower  and  outer  boundary  of  the  lesser  pectoral  having 


Fig.  433.— Halsted's  operation  for  carcinoma  of  the  breast:  the  first  incision. 

been  passed  and  exposed,  the  muscle  is  cut  at  a  right  angle 
to  its  fibers  and  a  little  below  the  middle.  The  tissue  over 
the  minor  muscle  near  its  coracoid  insertion  is  divided  as  far 
out  as  possible,  and  is  then  reflected  inward  to  prepare  for 
the  reflection  upward  of  this  part  of  the  minor  muscle. 
The  upper  portion  of  the  minor  muscle  is  retracted  upward 
(Fig.  434).  The  small  blood-vessels  under  the  minor  mus- 
cle are  carefully  separated  from  it,  are  dissected  out  very 
clear,  and  are  ligated  close  to  the  axillary  vessels.  Having 
exposed  the  subclavian  vein  at  the  highest  possible  point 
below  the  clavicle,  the  contents  of  the  axilla  are  dissected 
away  with  a  sharp  knife  and  the  vein  and  its  branches  are 
stripped  absolutely  clean.  The  loose  tissue  about  the  artery 
and  the  nerves  should  also  be  removed.  When  the  vessels 
are  cleared  the  axillary  contents  are  rapidly  stripped  from 
the  inner  walls  of  the  axilla  and  the  lateral  wall   of  the 


TUMORS    OF    THE   MAMMARY   GLAND. 


1067 


thorax.  The  fascia  which  binds  the  mass  to  the  chest  is  cut 
close  to  the  ribs  and  the  serratus  magnus  muscle.  Just 
before  reaching  the  junction  of  the  posterior  and  lateral 
walls  of  the  axilla,  an  assistant  draws  the  triangular  flap  of 
skin  outward  in  order  to  spread  out  the  tissue  which  lies 
upon  the  subscapularis,  teres  major,  and  latissimus  dorsi 
muscles.  The  operator  cleans  the  posterior  wall  of  the 
axilla  from  within  outward.  The  subscapular  vessels  are 
clearly  exposed,  and  are  caught  before  they  are  cut.  In  some 
cases  the  subscapular  nerves  are  removed,  in  others  they  are 
permitted  to  remain.     Having  passed  these  nerves  the  mass 


r 


00 


n 


.j 


Fig.  434. — Halsted's  operation  for  carcinoma  of  the  breast :  the  mass  turned  down. 


is  turned  back  into  its  normal  position  and  severed  from 
the  body  of  the  patient  by  a  stroke  of  the  knife  from  b  to  c, 
repeating  the  first  cut  through  the  skin.  Every  bleeding 
point,  however  small,  is  tied  with  fine  silk,  from  60  to  100 
ligatures,  or  even  more,  may  be  required. 

After  the  completion  of  the  operation  the  wound  into  the 
axilla  is  closed  with  a  subcuticular  stitch  of  silver  wire ;  if  a 
cut  has  been  carried  above  the  clavicle,  it  is  closed  in  the 
same  manner,  and  the  edges  of  the  elliptical  opening  are 
brought  nearer  together  by  a  purse-string  subcuticular 
stitch.  Thiersch  grafts  cut  from  the  patient's  thigh  are 
used  to  cover  the  gap.  Silver  foil  is  placed  over  the  wound, 
this  is  covered  with  gauze,  bandages  are  applied,  and  the 
dressing  is  overlaid  by  a  plaster-of-Paris  bandage,  which 
includes  the  head,  neck,  chest,  and  arm.  The  area  from 
which  grafts  were  taken  is  dressed  with  sterile  gauze  or  an 
ointment  containine  boric  acid. 


io68 


DISEASES    OF   THE   BREAST. 


A  very  useful  incision  is  that  described  by  the  younger 
Senn,  and  shown  in  Fig.  435. 
The  breast  is  circumscribed  by 
two  curvihnear  incisions  which 
meet  above,  at  the  border  of  the 
great  pectoral  muscle.  The  in- 
cision is  continued  a  little  internal 
to  the  outer  border  of  the  muscle 
to  about  one  inch  above  the  apex 
of  the  axilla,  when  it  is  curved 
outward  in  the  deltoid  region,  and 
terminates  at  the  level  of  the  apex 
of  the  axilla.  The  breast  is  re- 
moved from  the  wall  of  the  chest, 
and  is  then  suspended  by  axillary 
glands  and  fat,  which  are  removed 
en  masse}  This  incision  gives  a 
free  exposure,  opens  the  axilla 
from  in  front,  enables  the  surgeon 
to  quickly  locate  and  freely  ex- 
pose the  axillary  vein,  and  the  re- 
sulting scar  does  not  limit  materially  the  motions  of  the  arm. 


Fig.  435. — The   younger   Senn's   in 
cision  for  amputation  of  the  breast. 


XXXIX.  SKIAGRAPHY,  OR  THE  EMPLOYMENT  OF 
THE  RONTGEN  RAYS. 

The  cathode  rays  were  discovered  by  Hittorf,  in  1869, 
while  passing  an  induction  current  through  a  vacuum-tube. 
Crookes  of  London  greatly  improved  the  vacuum-tube,  and 
obtained  a  rarefaction  which  left  in  the  tube  but  the  one- 
millionth  of  an  atmosphere.  This  last-named  observer  found 
that  when  an  interrupted  current  of  high  potential  is  passed 
through  a  vacuum  which  is  nearly  perfect,  fluorescence  takes 
place.  In  a  Crookes  tube  the  positive  electrode  is  placed  at 
some  indifferent  point,  and  the  current  from  the  negative  elec- 
trode flows  not  to  the  positive,  but  directly  to  the  wall  of  the 
tube  opposite  the  cathode,  and  at  this  point  the  phospho- 
rescent glow  is  detected. 

In  1895,  Rontgen  of  Wiirzburg,  while  making  a  study  of 
cathode  rays  as  developed  in  Crookes's  tubes,  discovered 
the  energy  which  he  named  the  X-rays.  Rontgen  showed 
that  at  the  wall  of  the  Crookes  tube  opposite  the  nega- 
tive electrode  a  new  and  hitherto  unknown  energy  is  gen- 
erated.    Because  of  the  uncertain   character  of  this  energy 

^  See  the  younger  Senn  \\\  Jour.  Am.  Med.  Assoc,  May  27,  1899. 


SKIAGRAPHY.  I069 

he  gave  to  its  manifestation  the  name  of  the  X  or  unknown 
rays. 

The  A'-ra}'S  are  in\'isible ;  cannot  be  deflected,  reflected, 
refracted,  or  concentrated  ;  are  not  influenced  b}'  the  mag- 
net ;  and  produce  none  of  the  ordinarily  recognized  effects 
of  heat.  They  cause  fluorescence  in  certain  substances, 
notably  in  tungstate  of  calcium  (Edison),  platinocyanid  of 
barium  (Rontgen),  and  platinocyanid  of  potassium.  They 
have  a  marvellous  power  of  penetration,  and  pass  through 
many  substances  which  are  opaque  to  sunlight,  ultraviolet 
light,  and  ordinary  electric  light.  They  are  readily  trans- 
mitted b}'  water,  organic  substances,  leather,  cloth,  paper, 
and  flesh.  Bone  transmits  them  less  easily,  and  metal 
still  less  easily,  but  no  substance  absolutely  prevents  their 
transmission.  An  ordinary  dry  photographic  plate  is 
sensitive  to  the  rays.  If  the  rays  are  intercepted  by  a 
body  not  readih'  permeable  which  is  placed  between  the 
Crookes  tube  and  the  photographic  plate,  a  shadow  will  be 
cast,  and  a  picture  of  this  shadow  will  be  formed  upon  the 
plate.  Such  a  picture  is  knowm  as  a  skiagraph  or  radio- 
graph. If  a  body  more  or  less  resistant  to  the  rays  is  placed 
between  the  tube  and  a  fluorescent  screen,  the  body  casts  a 
shadow  on  the  screen,  and  the  portion  of  the  screen  free 
from  shadow  glows  with  fluorescence.  Such  a  screen  is 
known  as  a  fluoroscope.  It  will  thus  be  seen  that  the  X- 
rays  enable  the  surgeon  to  look  beneath  the  skin  and  to  see 
those  things  which  before  the  discovery  of  Rontgen  were 
unseeable  during  life.^ 

The  real  nature  of  the  A'-rays  is  unknown.  They  are  not 
heat-rays  ;  they  are  not  ultraviolet  rays.  Rontgen  thinks 
they  are  longitudinal  ether-waves.  Monell  says,  "  They 
appear  to  be  originated  at  the  site  of  the  greatest  electrical 
activity  within  the  tube,  and  their  real  nature  is  as  unknown 
as  the  nature  of  heat,  gravity,  electricity,  mind,  and  of  life 
itself." 

To  obtain  the  rays  a  good  apparatus  is  essential.  An 
ordinary  medical  battery  is  incapable  of  producing  them,  as 
it  is  absolutely  necessary  to  have  a  current  of  high  tension. 
The  discoverer  used  a  Ruhmkorff  coil,  but  this  is  by  no  means 
the  most  satisfactory  apparatus  to  employ.  Some  experi- 
menters have  made  use  of  a  "  powerful  static  machine  and 
transformer  coils"  (Monell).     Swinton  uses  twelve  half-gallon 

^  See  Rontgen's  report  to  the  Physico-Medical  Society  of  Wiirzburg,  Dec, 
1895  ;  also  the  article  upon  the  X-rays  by  S.  H.  Monell,  in  the  Brooklyn  Medical 
Jotinial,  May,  1S96. 


10/0  SKIAGRAPHY,   OR  EMPLOYMENT  OE  RONTGEN  RAYS. 

Leyden  jars  and  discharges  them  through  the  primary  coil, 
the  secondary  circuit  being  a  Tesla  oil  coil. 

The  current  is  best  taken  from  the  street-light  circuit. 
Monell  says  that  this  current  should  be  controlled  by  an 
interrupter,  the  interruptions  of  which  are  lOO  per  second. 
The  interrupted  current  is  to  be  passed  into  an  induction  coil, 
and  the  secondary  current  is  to  be  conveyed  into  the  Crookes 
tube  by  two  wires.  The  secondary  current  thus  produced 
will  furnish  a  spark  five  or  six  inches  long. 

When  the  surgeon  is  about  to  use  the  ^-rays,  he  must  re- 
move from  the  person  of  the  individual  anything  that  might 
cause  confusion  or  lead  to  error.  If  the  foot  is  to  be  exam- 
ined, remove  the  shoes,  because  shoes  contain  nails ;  if  the 
hand  is  to  be  examined,  remove  the  gloves  if  they  are  fast- 
ened with  buttons  of  bone  or  metal ;  if  the  thigh  is  to  be 
examined,  remove  coins,  keys,  knives,  etc.,  from  the  pocket; 
a  garter,  if  it  has  a  metal  clasp,  should  be  taken  off. 

In  order  to  get  the  best  results  from  the  Rontgen  rays,  not 
only  must  the  apparatus  be  good,  but  the  man  Avho  uses  it 
must  be  expert.  Pictures  taken  by  an  unskilled  man  lack 
clearness  of  outline,  and  may  even  lead  to  positively  erro- 
neous conclusions.  Nevertheless,  a  person  used  to  the  em- 
ployment of  scientific  apparatus  can  very  soon  become  suffi- 
ciently expert  to  take  fairly  clear  pictures  which  should  not 
lead  to  error.  Morris  H.  Richardson^  maintains  that  the 
Rontgen  rays  can  be  employed  successfully  in  the  routine 
office  practice  of  a  general  practitioner. 

The  surgeon  may  utilize  the  JT-rays  by  means  of  a  fluoro- 
scope.  Edison's  fluoroscope  consists  of  four  sides  of  a 
box,  one  end  being  open  and  made  to  fit  tightly  over 
the  observer's  eyes,  the  other  end  being  closed  with 
cardboard  made  fluorescent  by  smearing  it  with  mucilage, 
and,  before  the  mucilage  is  quite  dry,  sprinkling  it  with 
crystals  of  tungstate  of  calcium.  If  it  is  desired  to  examine 
the  hand  with  a  fluoroscope,  the  extremity  is  held  opposite 
an  excited  Crookes  tube  and  from  six  to  ten  inches  away 
from  it,  the  end  of  the  fluoroscope  which  is  covered  with 
fluorescent  paper  is  placed  near  the  surface  of  the  hand 
which  is  away  from  the  tube,  and  the  observer  looks  through 
the  other  end  of  the  instrument.  The  flesh  seems  but  a  dim 
haze  and  the  shadows  of  the  bones  are  distinctly  outlined. 
The  fluoroscope  can  be  easily  used,  and  gives  reliable  results 
in  studies  upon  the  hands  and  feet,  but  when  deeper  struct- 
ures are  to  be  investigated,  or  when   absolute  accuracy  is 

^  Medical  News,  Dec,  1896. 


SKI  A  GRA  PH  y.  1 07  I 

essential,  it  is  better  to  take  a  skiagraph.  The  value  of 
fluoroscopy  is  constantly  increasing  as  better  electrical  appli- 
ances and  Crookes's  tubes  are  being  made. 

If  thick  tissues  require  to  be  penetrated  b}-  the  rays,  if 
great  accurac}'  is  necessary,  or  if  a  permanent  record  is  to 
be  retained,  a  skiagraph  must  be  taken.  In  taking  these 
pictures  dry  plates  can  be  used ;  the  plate  need  not  be  re- 
moved from  its  wooden  case  during  the  process,  and  it  is  not 
necessary  to  conduct  the  proceeding  in  a  dark  room.  The 
tube  should  be  from  twelve  to  fifteen  inches  away  from  the 
surface  of  the  body.  The  plate  must  be  fastened  to  the 
surface  exactly  opposite  the  tube.  It  is  necessar}-  to  ob- 
serv^e  care  in  the  adjustment  of  the  plate,  because  the  ar- 
rays travel  only  in  straight  lines,  and  any  carelessness  of 
adjustment  will  lead  to  curious  and  misleading  aberration 
in  the  picture.  The  length  of  exposure  necessar}'  varies 
with  the  thickness  of  the  tissues,  the  structure  of  the 
part,  the  nature  of  the  body  we  wish  a  picture  of,  and  the 
perfection  of  the  apparatus,  from  three  minutes  to  one  hour. 
Prolonged  exposure  is  undesirable  if  it  can  be  avoided,  as  it 
may  produce  an  x-xzx  "  burn."  The  use  of  an  improper 
apparatus  or  placing  the  tube  too  close  to  the  body,  may  be 
followed  by  a  burn.  Occasionally,  in  spite  of  the  utmost 
care,  injury  will  be  done  by  the  ,i'-rays. 

The  so-called  ,t'-ray  "  burn  "  is  not  a  burn  at  all.  A  burn 
is  due  to  the  contact  of  heat,  begins  upon  the  surface,  is 
accompanied  with  pain  from  the  moment  of  application,  and  is 
followed  by  inflammator}'  changes,  beginning  on  the  surface. 
An  x-ray  "  burn  "  is  not  manifest  for  several  days  or  even 
several  weeks  after  the  application  of  the  rays,  at  which 
period  an  inflammatory  or  a  gangrenous  process  arises, 
which  begins  within  the  tissues  and  subsequently  involves 
the  surface.^  Inflammation  may  pass  away  or  may  eventuate 
in  gangrene,  and  a  gangrenous  area  is  white  in  color, 
"  leathery,  stringy,  tough  "  (Hopkins).  Hopkins  calls  the 
process  "  white  gangrene."  '  These  burns  are  often  accom- 
panied by  loss  of  hair  or  nails  in  the  damaged  area,  they 
require  months  to  heal,  if  they  heal  at  all,  are  very  painful, 
and  are  not  improved  by  the  treatment  which  relieves  ordinary 
burns.  In  some  cases  the  consequences  are  very  serious. 
In  a  case  reported  by  J.  P.  Tuttle,  it  became  necessary  to 
amputate  the  thigh.^     The  lesions  occasionally  produced  by 

1  E.  B.  Bronson,  in  the  debate  on  J-  B.  Tuttle's  case,  Aledical  Record,  March 
5,  1898.  2  Q    Q    Hopkins.  Philada.  Med.  Jour.,  January  6,  1900. 

^  Med.  Record,  May  5,  1898. 


10/2  SKIAGRAPHY,  OK  EMPLOYMENT  OE  RONTGEN  RAYS. 

the  ;i-rays  are  probably  trophic  changes.  Sections  made  by 
Vissman  from  Tuttle's  case  indicated  that  the  lesion  was  a 
gangrenous  process  due  to  arteritis  of  the  smaller  vessels. 
Various  theories  have  been  advanced  to  account  for  the 
occurrence  of  ,r-ray  gangrene,  viz. :  liberation  of  ozone  in 
the  tissues  (Tesla) ;  interference  with  cellular  nutrition  caused 
by  static  electric  currents  "  induced  by  the  introduction  of 
the  patient's  tissues  into  the  high  potential  induction-field 
surrounding  the  tube  "  (Leonard) ;  the  destruction  of  the 
nerve-supply  of  the  tissue  (Hopkins) ;  irritation  of  the  periph- 
eral extremities  of  the  sensory  nerves,  causing  paralysis  of 
the  vasomotors  (Rudis-Jicinsky) ;  an  electrolytic  action  of  a 
current  generated  in  the  tissues  by  induction  from  the  tube 
(Judd).  These  ,r-ray  injuries  are  most  liable  to  occur  when 
a  Ruhmkorff  coil  is  used,  and  such  a  condition  is  very 
rarely  caused  by  a  static  machine.  Hopkins  says  the 
lesions  "  are  produced  more  frequently  by  tubes  that  are 
energized  by  alternating  currents  than  by  those  energized  in 
any  other  way."  He  has  only  found  record  of  four  cases 
produced  w^hen  a  static  machine  was  used.  It  has  been 
suggested  that  a  thin  piece  of  aluminum,  a  plate  of  platinum, 
or  a  sheet  of  gold-leaf,  placed  upon  the  part  while  it  is  ex- 
posed to  the  ,r-rays  will  prevent  the  occurrence  of  these 
injuries.  Skin-grafting  may  succeed  in  remedying  an  ulcera- 
tion following  an  A'-ray  injury;  but,  as  a  rule,  the  grafts  do 
not  grow,  or  if  they  adhere  are  very^  apt  to  break  down  after 
a  time.  In  many  cases  the  best  treatment  is  excision  (Powell). 
The  uses  of  the  ;r-rays  are  legion.  They  are  of  the 
greatest  possible  value  in  the  location  of  foreign  bodies, 
especially  bodies  of  metal,  glass,  or  bone,  such  as  bullets, 
and  needles,  glass,  sphnters,  etc.  Bullets  are  readily  de- 
tected in  the  extremities;  have  been  found  in  the  lung- 
substance  and  bronchi  (Rowland),  in  the  brain  (Schier,  Bris- 
saud  and  Londe,  Henchen  and  Sennauer,  Biuce,  Willy 
Meyer),  in  the  abdomen,  the  pelvis,  a  joint,  the  spine,  and 
the  eye.  The  jr-rays  will  enable  us  after  an  abdominal 
operation  to  locate  a  Murphy  button  and  tell  when  it  has 
loosened  and  descended.  Foreign  bodies,  especially  if 
metallic,  in  the  esophagus,  stomach,  intestine,  and  air-pas- 
sages;  enteroliths  and  mineral  calculi  in  the  sali\-ary  ducts, 
bladder,  ureter,  and  kidney  can  be  detected.  Heniy  IMorris 
tells  us  that  a  calculus  m  the  kidney  may  exist  and  yet 
•escape  detection  with  the  rays,  because  the  kidney  is  very 
deeply  placed,  is  under  the  ribs  and  close  to  the  verte- 
bral column.    Occasionally  a  drainage-tube  lost  in  the  pleural 


KUNTGEN   RAYS. 


Plate  S. 


2  3 

1.  Gunshot-wound  of  the  Lung.  Rib-re.^ection  for  secondary  hemorrhage  into  the 
pleural  sac  ten  days  after  the  injury;  bullet  not  removed.  Hemorrhage  arrested  by  pack- 
ing with  gauze.     Skiagraph  taken  three  months  afterward  shows  the  bullet.     (Author's  case.) 

2.  Fracture  of  Lower  End  of  the  Femur.  Reduction  of  fragments  impossible  because 
of  the  iiiierposition  of  a  loose  piece  of  bone  and  much  muscle  between  fragments.  (Author's 
case.) 

3.  Case  shown  in  Figure  2,  Three  Months  after  the  Operation  of  Wiring.  Nine  months 
after  operation,  the  man  is  walking  about  with  ease,  and  the  wire  is  still  in  place. 

(The  above  skiagraphs  are  from  the  A'-Ray  Laboratory  of  the  Jefferson  Medical  College 
Hospital.  \ 


SKIAGRAPHY. 


1073 


sac  may  be  discovered.  Most  observers  state  that  gall-stones 
cannot  be  skiagraphed  in  the  living  body.  Cattell  has  suc- 
ceeded in  one  case.  Carl  Beck  has  succeeded  in  skiagraphing 
cholelithiasis.^  The  rays  may  fail  to  disclose  a  foreign  body 
because  of  its  being  overshadowed  by  a  bone  (Carless),  but 
prolonged  exposure  or  the  taking  of  another  picture  with  the 
part  in  another  position  will  bring  it  into  view.  In  many 
cases  a  skiagraph  does  not  indicate  how  deeply  in  the  tissues 
a  foreign  body  lies,  or  upon  which  side  of  a  bone  it  is  lodged.^ 


Fig.  436. — W.  1\I.  Sweet's  ^-ray  apparatus  for  locating  foreign  bodies. 


If  there  is  doubt,  take  several  pictures  from  different  positions 
(triangulation),  skiagraph  over  a  surface  marked  in  squares, 
insert  guide-needles  into  the  tissues  before  taking  the  final 
picture,  or  employ  Sweet's  apparatus.  Sweet's  apparatus 
has  been  used  successfully  for  the  location  of  foreign  bodies 
in  the  eye,  but  a  modification  of  the  original  apparatus 
has   recently  been  used   to   skiagraph   other  regions   of  the 


N.   Y.  Med.  Jour.,  January  20,  1900. 
Battle's  case  in  Lancet,  February  29,  1896. 


68 


I074  SKIAGRAPHY,   OR  EMPLOYMENT  OE  RONTGEN  RA  YS. 

body.  Sweet's  apparatus  is  used  as  follows  :  ^  "  The  essen- 
tial features  of  this  apparatus  and  the  method  of  employing 
it  are  shown  in  the  illustration  (Fig.  436).  An  adjustable 
arm  carries  two  ball-pointed  rods  which  are  at  a  known  dis- 
tance apart,  and  are  parallel  with  each  other  and  with  the 
photographic  plate,  while  the  balls  are  perpendicular  to  each 
other  and  the  plate. 

"  When  the  skiagraphs   are   made,  one  of  the  indicator- 
balls  rests  against  the  skin  at  any  point  in  the  neighborhood 


Fig.  437. — Skiagraph  made  with  tube  huri/.uiittil  to  plane  of  indicators.     The  bullet  is  well 
seen.     Opposite  A  are  seen  the  two  balls  at  the  ends  of  the  rods. 

of  the  foreign  body,  while  the  second  indicator  is  toward  the 
plate.  The  spot  on  the  skin  at  which  one  of  the  indicator- 
balls  rests  is  marked  with  silver  nitrate,  as  the  position  of  the 
foreign  body  is  measured  from  this  point. 

"  Two  skiagraphs  are  made  to  give  different  relations  of 
the  shadows  of  the  two  indicators  and  the  bullet,  one  expo- 
sure with  the  tube  horizontal,  or  nearly  so,  with  the  plane  of 
the  indicators,  and  a  second  exposure  with  the  tube  at  any 
distance  above  or  below  this  plane.  Since  the  shadow  of 
the  foreign  body  preserves  at  all  times  a  fixed  relation  with 

1  W.  W.  Keen,  in  Philada.  Med.  Jour.,  January  6,  1900. 


SKIAGRAPHY.  IO75 

respect  to  the  shadows  of  the  two  indicator-balls  in  what- 
ever position  the  tube  is  placed,  and  since  the  situation  of 
two  balls  is  known,  the  location  of  the  foreign  body  in  the 
tissues  is  readily  determined  from  a  study  of  the  planes  of 
shadow  at  the  two  exposures. 

"  When  the  skiagraphs  of  the  case  here  reported  were 
made,  the  anterior  surface  of  the  leg  was  placed  upon  the 
bottom  of  the  right-angle  support  of  the  apparatus,  the  plate 
to  the  inner  side  of  the  knee,  one  indicator-ball  resting  on 
the  skin   nearly  in  the  center  of  the  popliteal  space.     The 


Fig.  4,8.— Skiagraph  made  with  tube  above  horizontal  plane  of  indicators      The  bullet  is 
well  shown.     Opposite  A  and  B  are  seen  the  two  balls  at  the  ends  of  the  rods. 


skiagraph  made  with  the  tube  horizontal  with  the  plane  of 
the  indicators  is  shown  in  Fig.  437,  and  the  second  skia- 
graph with  the  tube  a  short  distance  above  the  first  position 
is  seen  in  Fig.  438.  Both  negatives  show  the  leg  as  viewed 
from  the  outer  side,  with  the  posterior  surface  of  the  leg 
uppermost. 

"  In  determining  the  position  of  the  bullet  a  spot  is  made 
upon  paper  to  indicate  the  point  on  the  skin  at  which  one 
of  the  indicator-balls  rested  at  the  time  of  the  exposures,  a 
second  spot  being  made  two  inches  from  the  first,  to  repre- 


10/6  SKIAGRAPHY,  OR  EMPLOYMENT  OF  RONTGEN  RAYS. 


sent  the  fixed  distance  between  the  two  balls.  These  are 
shown  at  A  and  B,  upper  diagram,  Fig.  439.  The  first  nega- 
tive is  now  taken.  The  distance  the  shadow  of  the  bullet  is 
below  the  shadow  of  each  of  the  two  indicators  is  measured, 
and  this  distance  entered  below  the  spots  representing  the 
two  balls  when  the  exposure  was  made  (6' and  D).  A  line 
drawn  through  these  points  indicates  the  plane  of  shadow  of 
the    bullet    when   the   first   skiagraph    was    made.      Similar 

measurements  are  made 
from  the  second  negative 
and  marked  below  the 
spots  A  and  B,  the  line 
through  the  spots  (/^and 
//"),  giving  the  plane  of 
shadow  when  the  second 
negative  was  made.  Where 
these  two  planes  of  shadow 
cross  (^Y)  is  the  position 
of  the  bullet  as  measured 
below,  and  to  the  inner 
side  of  the  nitrate  of  silver 
spot  on  the  skin. 

"  In  determining  the 
depth  of  the  bullet  in  the 
tissues,  a  second  diagram 
is  made  to  indicate  the 
position  of  the  two  balls, 
as  viewed  from  a  cross- 
section  of  the  leg.  Since 
the  tube  was  only  twenty- 
four  inches  away  at  the 
time  of  the  exposure,  the 
convergence  of  the  rays 
in  an  object  as  large  as 
the  leg  must  be  allowed 
for.  This  is  done  by 
measuring  the  distance  the  shadow  of  one  ball  is  behind 
that  of  the  other,  entering  this  distance  {A  K)  on  the 
diagram,  and  marking  on  a  line  through  this  point,  twenty- 
four  inches  from  the  ball  resting  on  the  skin,  the  situation 
of  the  tube.  If  we  now  measure  the  distance  the  shadow 
of  the  bullet  on  the  first  negative  is  back  of  that  of  the 
shadow  of  the  ball  on  the  skin,  enter  this  distance  in  the 
plane  of  this  indicator  [B  M),  and  draw  a  line  from  the 
situation  of  the  tube  through  this  point,  we  obtain  the  plane 


Fig.  439. — .Method  of  indicating  location  of 
bullet.  Upper  diagram,  posterior  view  of  leg 
from  above.  Lower  diagram,  cross-section  of  leg, 
near  knee-joint. 


SKIAGRAPHV.  lO// 

of  the  shidovv  of  the  bullet  when  the  exposure  was  made. 
Drawing  a  line  from  the  position  of  the  bullet  as  previously 
found  on  the  first  diagram  the  intersection  of  this  line  with 
the  plane  of  shadow  upon  the  second  diagram  gives  the 
situation  of  the  bullet  from  a  cross-section  view  of  the  leg. 
For  purposes  of  greater  clearness,  outlines  of  the  leg  have 
been  shown  in  the  two  diagrams,  although  this  is  unneces- 
sary in  practice,  since  the  position  of  the  foreign  bod}-  in 
respect  to  a  known  point  upon  the  integument  is  all  that  is 
required.  The  position  of  the  bullet  was  shown  to  be  one 
inch  toward  the  inner  side  of  the  spot  on  the  skin  at  which 
one  of  the  indicator-balls  rested,  one  and  a  quarter  inches 
below  this  spot,  toward  the  ankle,  and  embedded  in  the 
tissues  to  the  depth  of  one  and  a  half  inches.  Both  skia- 
graphs show  the  bullet  close  to  the  bone,  but,  owing  to  the 
false  projection,  so  common  in  all  ,t'-ray  pictures,  it  is 
impossible  to  say  whether  the  bullet  was  embedded  in 
the  bone  or  not." 

In  detecting  fractures  and  dislocations  the  Rontgen  rays 
are  of  great  value,  especially  when  there  is  much  swelling, 
when  there  is  little  displacement,  and  when  the  fracture  is  in 
or  about  a  joint.  The  rays  enable  us  to  determine  the 
nature  of  the  injuiy,  the  amount  of  splintering,  the  exist- 
ence of  impaction,  the  question  whether  or  not  the  frag- 
ments are  in  contact  and  can  be  brought  into  contact;  the 
direction  of  the  line  of  fracture,  the  variety  of  deformity, 
the  existence  of  more  than  one  fracture,  the  presence  of 
epiphyseal  separation  or  dislocation  alone  or  with  a  fracture, 
the  existence  of  an  ununited  fracture,  and  the  question  if  the 
splints  are  holding  the  fragments  in  accurate  apposition. 
Fractures  of  the  skull,  if  involving  both  tables  of  the  vault, 
may  be  recognized ;  it  is  possible  that  fractures  of  the  inner 
table  may  be  found ;  fractures  of  the  base  can  be  seen,  but 
with  difficulty  (White).  Fractures  of  the  spine  never  show 
veiy  clearly.  To  take  a  picture  of  a  fractured  rib,  first  limit 
chest-motion  by  bandaging  (White).  Morris  tells  us  to  be 
somewhat  skeptical  in  accepting  unreservedly  the  evidence 
offered  by  a  skiagraph,  as  slight  carelessness  in  taking  the 
picture  may  mean  great  distortion  and  consequent  error.  The 
Jf-rays  may  be  of  value  in  enabling  the  surgeon  to  recognize 
rheumatoid  arthritis  ;  bone-  and  joint-tuberculosis  (the  tuber- 
cular area  being  lighter  than  the  sound  bone) ;  the  amount  of 
acetabular  rim  present  in  congenital  dislocation  of  the  hip-joint 
(Rowland) ;  the  state  of  the  bones  in  a  crushed  limb  (J.  Hall 
Edwards) ;  bone  deformity  ;  osseous  tumors  ;  bone  displace- 


10/8  INJURIES  BY  ELECTRICITY. 

ment  (as  in  Morton's  foot);  osteomyelitis;  caries;  necrosis; 
and  osteosarcoma.  By  skiagraphy  we  are  enabled  to  decide  on 
the  proper  situation  to  perform  osteotomy,  and  if  a  deformity 
of  the  foot  can  be  amended  without  operation  (Willard). 
The  position  of  the  fetus  in  utero  can  be  definitely  made  out. 
Applied  to  the  soft  parts,  the  new  process  has  obtained 
interesting  but  not  as  yet  many  practically  useful  results. 
Fibrous  tumors  can  be  seen,  but  malignant  tumors,  unless 
they  contain  calcareous  or  fibrous  elements,  cannot  be  defi- 
nitely made  out ;  loose  bodies  in  a  joint  can  often  be  detected. 
The  shadow  of  the  heart  can  be  made  out,  and  the  outlines 
of  the  diaphragm,  kidney,  and  liver  can  be  thrown  upon  the 
screen.  If  the  stomach  is  distended  with  gas,  it  shows  as  a 
light  area  upon  a  dark  background  (Hedley).  If  food  is 
eaten  after  being  mixed  with  subnitrate  of  bismuth,  the  out- 
line of  the  viscus  becomes  fairly  distinct.  Thickened  pleura, 
pleural  effusion,  pulmonary  consolidation,  pericardial  effu- 
sion, aortic  aneurysm ;  cavities  in  the  lungs,  and  atheromatous 
blood-vessels  may  be  made  out  with  more  or  less  distinctness. 
If  a  sinus  is  injected  with  iodoform  emulsion,  a  picture  of  it 
can  be  taken,  because  the  emulsion  casts  a  shadow  when 
placed  in  the  path  of  the  X-rays  (J.  Hall  Edwards).  Up  to 
the  present  time  no  positive  evidence  has  been  offered  to 
prove  that  the  Rontgen  force  is  possessed  of  any  therapeutic 
value. 

XL.  INJURIES  BY  ELECTRICITY. 

Bffects  Produced  by  I^ightning. — An  indi\idual  ma\' 
be  struck  directly,  or  he  may  be  shocked  by  an  induced  cur- 
rent, the  lightning  having  struck  a  nearby  object.  A  person 
can  be  struck  while  in  a  room,  but  there  is  more  danger 
when  exposed  especially  in  the  open  country.  To  be 
under  a  single  tree  during  a  thunderstorm  is  dangerous, 
but  to  be  in  a  wood  or  under  a  hedge  is  reasonably  safe. 
The  victim  of  lightning  may  be  killed  instantly.  Death 
is  the  fate  of  over  one  third  of  those  struck.  Tidy  states 
that  out  of  54  cases,  21  died  and  33  recovered.  Post- 
mortem examination  may  fail  to  reveal  a  lesion,  but  in 
many  cases  severe  burns  are  discovered ;  in  some  there  are 
laceration  of  tissue,  crushing  of  bones,  and  fearful  injury. 
Burns  are  especially  apt  to  occur  at  the  points  where  the 
current  entered  and  emerged.  The  clothes  are  usually 
singed  and  torn.  The  typical  lightning-marks  are  arborescent 
tracings,  representing  the  course  of  blood-vessels,  produced 


IXJUR/ES  fiV  ELECTRICTTY.  IO79 

by  disorganization  and  effusion  of  blood  as  the  fluid  tra\'els 
through  it.  Occasionally  metal  objects,  such  as  buttons, 
knives,  mone\',  keys,  etc.,  are  fused,  and  spread  as  a  metallic 
film  over  a  considerable  portion  of  the  surface  of  the  body. 
Bichat  stated  that  in  death  from  lightning  rigor  mortis  does 
not  occur.  This  statement  is  now  known  to  be  an  error  (see 
the  three  cases  reported  by  M.  Tourdes).  As  a  rule,  there 
is  early  vigor  mortis,  retained  fluidity  of  blood,  and  disten- 
tion of  the  brain  with  venous  blood.  The  cause  of  death  by 
lightning  was  supposed  by  Hunter  to  be  due  to  destruction 
of  muscular  contractility,  and  by  Richardson  to  the  resolu- 
tion of  the  blood  into  gases.  It  seems  probable  that  some 
deaths  are  due  to  actual  disorganization  of  vital  structure 
and  that  others  are  due  to  shock  or  inhibition.  In  many 
cases  struck  by  lightning  recovery  will  take  place  even  when 
the  indi\-idual  is  apparoitly  dead.  Sestier  reported  'jy  cases 
struck  by  lightning,  and  in  7  of  them  the  persons  were 
apparently  dead  for  a  number  of  hours. ^  Brouardel  says  in 
such  cases  the  death-like  state  may  be  ascribed  to  inhibition, 
caused  b}^  a  viaxiJiiiiin  degree  of  stimulus.^  When  death 
from  lightning  is  not  immediate  the  condition  may  be  as  above 
outlined,  the  individual  being  apparently  dead,  without  ob- 
vious respiration  or  pulse.  He  may  be  insensible,  with  slow 
and  labored  respiration,  a  weak  and  irregular  pulse,  and 
dilated  pupils,  and  may  remain  in  this  condition  for  a  few 
minutes  or  for  several  hours.  The  above  condition  is  not  to 
be  distinguished  from  severe  concussion  of  the  brain.  Every 
individual  suffering  from  the  effects  of  lightning  should  have 
his  entire  body  carefulh'  examined  to  see  if  physical  injuries 
exist  (fractures,  wounds,  burns,  ecchymoses,  arborescent 
tracings).  The  consequences  of  lightning-stroke  are  many 
and  \^arious.  There  may  be  rapid  and  complete  recovery, 
gradual  recovery,  traumatic  neurasthenia,  sloughing  burns, 
partial  paralysis,  which  is  usually  recovered  from  (Noth- 
nagel),  but  which  may  be  permanent,  h}'steria,  blindness, 
change  of  character,  and  actual  insanit}\ 

Treatment. — Do  not  pronounce  a  person  dead  until  a  thor- 
ough attempt  at  resuscitation  has  .been  made.  Do  not  give 
alcoholic  stimulants.  If  the  respiration  is  feeble  and  apparently 
absent,  make  tongue  traction  and  artificial  respiration.  Apply 
the  stream  of  a  cold  douche  to  the  head,  rub  the  limbs  \\ith 

^  Sestier,  De  la  Foudre,  Paris,  1866.  Quoted  by  Brouardel  in  his  lectures 
upon  "Death  and  Sudden  Death." 

*  Benham"s  translation  of  Brouardel's  lectures  upon  "  Death  and  Sudden 
Death." 


I080  INJURIES  BY  ELECTRICirY. 

mustard,  put  a  mustard  plaster  over  the  heart  and  another  to 
the  back  of  the  neck,  wrap  the  individual  in  hot  blankets, 
and  give  enemata  of  hot  saline  fluid.  In  some  cases  venesec- 
tion has  seemed  to  be  of  benefit.  When  the  individual  reacts 
treat  any  existing  condition  symptomatically,  and  treat  par- 
ticular physical  injuries  according  to  their  character. 

Effects  of  Artificial  Currents. — Workmen  for  electric 
companies ;  pedestrians  in  the  streets  of  a  city  which  is 
lighted  by  electricity  or  in  which  trolley  cars  are  em- 
ployed; roofers  and  firemen  are  liable  to  be  injured  by 
electricity.  An  alternating  current  is  decidedly  more 
dangerous  than  a  continuous  current  of  equal  strength. 
An  artificial  current  acts  like  lightning.  It  may  produce 
instant  death  ;  it  may  produce  unconsciousness,  dehrium,  ster- 
torous respiration,  Cheyne-Stokes'  breathing,  or  clonic  spasms. 
Its  effects  can  be  often  recovered  from.  Not  unusually  the 
victim  is  apparently  dead,  but  subsequently  recovers.  D'Ar- 
sonval  reports  the  case  of  a  man  who  was  apparently  killed 
by  the  passage  of  4500  volts.  No  attempt  at  resuscitation  was 
made  for  one-half  an  hour,  and  yet  he  recovered  when  artificial 
respiration  was  employed.  Donnellan  reports  a  case  of  re- 
covery after  the  passage  of  looo  volts.  Slight  shocks  may 
cause  temporary  numbness,  and  even  motor  paralysis.  An 
electric  shock  frequently  causes  burns  or  ecchymoses,  and  oc- 
casionally wounds.  Wounds  caused  by  electricity  bleed  pro- 
fusely and  are  apt  to  slough.  An  electric  burn  looks  like  a 
blackened  crust;  it  is  surrounded  by  pale  skin,  and  for  twenty- 
four  hours  remains  dry,  when  inflammatory  oozing  begins  and 
the  skin  around  it  reddens.  These  burns  are  not  as  painful  as 
are  ordinary  burns,  but  recovery  requires  a  long  time.  When 
inflammation  begins  and  suppuration  occurs,  tissue  is  exten- 
sively destroyed,  tendons,  bones,  and  joints  may  suffer,  some 
portions  become  deeply  excavated,  and  other  portions  show 
dry  adherent  masses  of  dead  and  dying  tissue,  and  a  burn 
which  was  at  first  small  may  be  followed  by  a  large  area  of 
moist  gangrene;^  lack  of  tissue-resistance,  due  to  trophic  dis- 
turbance, is  largely  responsible  for  the  progress  of  the  slough- 

Treatment. — If  a  person  is  in  contact  with  a  live  wire,  the 
first  thing  to  do  is,  if  possible,  to  shut  off  the  current.  If  it 
is  not  possible  to  shut  off  the  current,  catch  a  portion  of  the 
clothing  of  the  victim  and  pull  him  away  from  the  w"ire, 
but  do  not  touch  his  body  with  the  bare  hand.     If  a  pair  of 

1  See  the  article  by  N.  W.  Sharpe  on  "'Peculiarities  and  Treatment  of  Elec- 
trical Injuries,"  in  Phila.  Med.  Jour.,  Jan.  29,  1898. 


I.VJi'RIES  BY  ELECTRICITY.  ]08l 

rubber  gloves  can  be  obtained,  the  subject  can  be  moved 
with  impunit\'  and  the  wires  can  be  safely  cut.  If  it  is  not 
possible  to  drag  a  person  away  from  electric  wires,  the  sur- 
geon can  wrap  his  hands  in  dry  cloth  and  lift  the  portion 
of  the  body  in  contact  with  earth  or  wire,  and  thus  break  the 
circuit  and  permit  of  removal  of  the  body.'  A  diy  cloth  can 
be  pushed  between  the  body  and  the  ground,  and  the  body 
can  then  be  removed  from  the  wires.  It  may  be  possible  to 
push  the  wires  away  by  means  of  a  dry  piece  of  wood,  or  to 
cut  them  with  shears  which  have  wooden  handles  and  which 
are  perfectly  dry.  Treat  the  general  condition  in  the  manner 
set  forth  in  the  article  on  lightning-stroke  (page  879).  Veiy 
severe  burns  may  be  caused.  The  author  has  dressed  a  num- 
ber of  electric  burns  with  hot  fomentations  of  salt  solution 
during  the  first  few  days.  This  facilitates  the  separation  of 
the  sloughs  and  seems  to  aid  the  weakened  tissues  in  resist- 
ing microbic  invasion ;  after  sloughs  separate,  the  part  is  ■ 
dressed  with  dr}'  sterile  gauze.  Antiseptic  dressings  can  be 
used  from  the  beginning,  but  they  often  fail  entirely  to  arrest 
the  sloughing.  Iodoform  produces  much  irritation.  Ointments 
are  very  unsatisfactory.  When  the  dressings  are  changed  the 
part  should  not  be  washed  with  corrosive  sublimate,  as  this 
agent  produces  much  irritation  ;  peroxid  of  hydrogen  should 
be  employed,  followed  by  hot  normal  salt  solution.  Sharpe 
removes  sloughs  by  applying  the  following  mixture :  2  parts 
of  scale  pepsin,  i  part  of  hydrochloric  acid,  U.S.P. ;  120 
parts  of  distilled  water.  This  mixture  is  washed  off  after 
two  hours  with  peroxid  of  hydrogen.  The  same  surgeon 
treats  necrosis  of  bone  by  injecting  every  few  hours  a  3  per 
cent,  solution  of  hydrochloric  acid,  using  every  second  day 
the  pepsin  solution,  and  when  necrotic  areas  come  away 
packing  with  gauze.  Skin-grafting  by  Reverdin's  method 
or  Thiersch's  method  is  rarely  successful.  In  some  regions  it 
is  possible  to  slide  a  large  flap  in  place  to  cover  a  granulat- 
ing area  which  will  not  heal.  In  a  wtxy  severe  case  amputa- 
tion or  resection  may  be  necessary. 

^  See  the  directions  in  Med.  Record,  Dec.  28,  1895,  ^o^^  Med.  Press. 


INDEX. 


Abbe's  method  of  intestinal  anastomo- 
sis, 844 
Abdomen,  diseases  and  injuries  of,  760 
gunshot  wounds  of,  768 
operations  on,  813 
Abdominal  hernia,  857 
section,  813-816 

wall,  contusion   of,  muscular   rupture 
from,  760 
contusion  of,  without  injury  of  vis- 
cera, 760 
wounds  of,  765 

non-penetrating,  765 
penetrating,  766 
Abernethy's  extraperitoneal  method  for 
ligation  of  external  iliac,  385 
fascia,  384 
Abscess,  118,  123 
acute,  123 

diagnosis,  129 
in  various  regions,  127 
prognosis,  130 
symptoms,  126 
treatment,  130 
appendiceal,  127 
treatment,  131 
appendicular,  127 
Benzold's,  678 
Brodie's,  126,  136,  393 
cerebral,  from  ear  disease,  678 
chronic,  134 
cold,  134 

deep,  treatment,  132 
dorsal,  136,  140 
extradural,  679 
forms  of,  125 
iliac,  136,  184 
ischiorectal,  128,  888 
treatment,  131,  714 
large  cold,  138 
lumbar,  137,  140 
lymphatic,  134 
of  antrum  of  Highmore,  128 
of  appendix,  819 
of  bone,  392 
Brodie's,  393 
chronic,  137,  393 
of  brain,    127,   675.     See  also   Brain, 
abscess  of. 
treatment,  132 
of  breast,  129,  1056 
chronic,  137 
treatment,  132 


Abscess  of  frontal  sinus,  715 

of  hip,  518 

of  kidney,  954 

of  larynx,  128 

of  liver,  127,  804 
treatment,  131 

of  lung,  128,  733 
treatment,  131 

of  lymphatic  glands,  cold,  138 

of  mammary  gland,  cold,  138 

of  mediastinum,  128 

of  scalp,  655 

of  spleen,  812 

palmar,  129,  621 

perinephric,  128,  956 

pointing  of,  124 

postpharyngeal,  136,  140 

prostatic,  129 

from  gonorrhea,  treatment,   1008 

psoas,  136,  138 

residual,  196 

retropharyngeal,  136 

scrofulous,  134 

shirt-stud,  133 

spinal,  treatment,  703 

spontaneous  evacuation  of,  124 

subphrenic,  127,  801 

superficial,  treatment,  132 

tuljercular,  134 

in  various  regions,  136 
of  head  of  bone,  136 
symptoms,  135 
treatment,  137 
A.  C.  E.  mixture,  906 
Acetabulum,  fractures  of,  442 
Acetanilid,  30 
Achillodynia,  276 
Acne,  246 
Acromegaly,  403 
Actinomycosis,  19,  235,  267 

of  bone,  236,  389 

treatment,  236 
"  Active  clot,"  312 

hyperemia,  61 
Actol,  30 
Acupressure  in  aneurysm,  321 

in  hemorrhages,  332 
Adam's  large  saw,  585 

operation,  587 
Adenocele  of  mammary  gland,  1060 
Adenoma,   cystic,   of  mammary  gland, 

1060 
Adenomata,  292 

1083 


1084 


INDEX. 


Aerobic  bacteria,  23 

Agnew's  operation  for  webbed  fingers, 

634 
Air-embolism,  173 
Air-passages,  foreign  bodies  in,  716 
Albert's  disease,  276,  625 
Albuminuria  in  syphilis,  252 
Alcoholic  stimulants,  102 
Aleppo  boil,  917 
Alexander's  rules  for  catheterization  in 

hypertrophy  of  prostate  gland, 

1026 
Alexins,  34,  37 
Alimentary  canal,  foreign  bodies  in,  768 

tuberculosis  of,  195 
Alkaline  iodids,  loi 
Allingham's     decalcified    bone-bobbin, 

839 
operation  for  hemorrhoids,  881 
Allis's  ether-inhaler,  898 

plan  of  reduction   for  dislocation  of 

femur,  577 
sign,  476 
Almen's  test  for  blood  in  urine,  943 
Alopecia  in  syphilis,  248 
Ambulatory  dressing  apparatus  for  thigh , 
420 
of  plaster-of-Paris  for  leg,  420 
treatment  of  fractures,  420 
Ameboid  movements  of  leukocytes,  66 
American  bandage  of  foot,  930 
Amputations,  1035 
a  la  manchette,  1038 
at  ankle-joint,  1047 

Pirogoff's  method,  1048 
Syme's  method,  1047 
at  hip-joint,  1053 

Jordan's  (Forneaux)   method,  1055 
Wyeth's  bloodless  method,  1054 
at  metacarpophalangeal  joint,  1041 
at  shoulder-joint,  1043 

Dupuytren's  method,  1044 
Lisfranc's  operation,  1044 
Larrey's  operation,  1043 
at  tarsometatarsal  articulation,  1045 
Hey's  method,  1046 
Lisfranc's  method,  1045 
Berger's,  1044 
by  transfixion,  1040 
catlin  for,  1037 
chart  of,  597,  598 
Chopart's,  1047 
classification,  1035 
for  aneurysm,  321 
for  fractures  423 
for  gangrene,  rules  for,  167 
for  gunshot-wound,  225 
hemorrhage  in,  103S 
intermediate,  1035 
knife  for,  1037 
methods  of,  1038 
circular,  1038 

modified,  1039 
elliptical,  1039 
flap,  1039 


Amputations,  methods  of,  oval,  1039 
racket,  1039 
of  arm,  1043 

by  circular  method,  1038 
of  breast,  Senn's  incision  for,  1068 
of  entire  upper  extremity,  1044 
Berger's  operation,  1044 
of  fingers,  1040 
of  foot,  1045 
of  hand,  1040 
of  leg,  1048 

at  disarticulation  of  knee,  1051 
below  knee,  1051 
Bier's  method,  1049 
by  lateral  flaps,  1050 
by  long  anterior  flap,  1049 
by  long  posterior  and  short  ante- 
rior flap,   1050 
by  rectangular  flap,  1049 
modified  circular  method,  1050 
Sedillot's  operation,  1049 
Teale's  method,  1049 
through  femoral  condyles,  1051 
Gritti's  operation,  1051 
Sabanejeff's  operation,  1052 
Syme's  method,  1051 
of  penis,  1023 
of  thigh,  1052 
of  thumb,  1041 
of  toes,  1045 
of  wrist-joint,  1042 
primary,  1035 
saws  for,  1037 
secondary,  1035 
special,  1040 
T-,  1054 

through  forearm,  1042 
through  middle  tarsal  joint,  1047 
Chopart's  method,  1047 
through  tarsus,  1047 
Amyloid  degenerations  in  syphilis,  251 
Anaerobic  bacteria,  23 
Anastomosis,  aneurysms  by,  283 
intestinal,  835 

Laplace's  forceps  for,  842 
lateral,  843 
with  rings,  843 
Maunsell's  method  of,  838 
Anatomical  snuff-box,  360 
Anderson's  method  of  tendon-lengthen- 
ing, 631 
Anel's  operation  for  aneurysm,  318 
Anesthesia,  893 
by  freezing,  908 
closure  of  epiglottis  in,  902 
complications  in,  treatment,  900 
cyanosis  in,  901 
infiltration-,  910 
local,  908 
primary,  905 
reaction  from,  902 
shock  in,  900 

swallowing  of  tongue  in,  900,  901 
syncope  in,  900 
vomiting  in,  900 


INDEX. 


1085 


Anesthetic  state  from   ether  or  chloro- 
form, 898 
Anesthetics,  893 
after-effects  of,  903 
renal  complications  after,  904 
respiratory  disorders  after,  904 
vomiting  after,  903 
Aneurysm,  310 
acute,  311 

arteriovenous,  311,  323 
by  anastomosis,  283,  311,  324 
capillary,  311 
circumscribed,  311 
cirsoid,  283,  324 
consecutive,  310 
cylindrical,  311 
diagnosis,  315 
dissecting,  310 
embolic,  311 
false,  310 
forms  of,  310 
fusiform,  310 
miliary,  311 
of  bone, 311 

operation  for,  Anel's,  318 
Antyllus's,  318 
Brasdor's,  320 
Corradi's,  321 
Hunter's,  318 
Pott's,  311,  323 
Wardrop's,  320 
rupture  of,  312 
sacculated,  310,  311 
secondary,  311 
Shekelton's,  310 
spontaneous,  311 
traumatic,  310,  322 
treatment,  315 
true,  310 
varicose,  323 
veruminous,  311 
Aneurysmal  varix,  311,  323 
Aneur'ysm-needles  of  Dupuytren,  356 

of  Saviard,  356 
Angina,  Ludwig's,  166 

Ludovici,  166 
Angioma  of  mammary  gland,  1061 
Angiomata,  282 
Angiosarcoma,  288 

Angle's   bonds   in    treatment    of   fract- 
ure of  inferior  maxillary  bone, 

433 
Ankle-joint,  amputation  at,  1047 

disease,  526 

dislocations  of,  581.     See  also  Dislo- 
cations of  ankle-joint. 

excision  of,  606 
Ankylosis,  543 

bony, 543 

extra-articular,  546 

false,  546 

fibrous,  543,  544 

intra-articular,  543 

osseous,  543 

true,  543 


Annular  ligament,  method  of  suturing, 

631 
Anodynes,  99 
Anterior  tibial  artery,  377 

ligation  of,  378.     See  also  Ligation.     ' 
triangles  of  neck,  369 
Anthrax,  230 

bacillus  of,  41,  43 
benign, 917 
carbuncle,  230 
forms  of,  230 
treatment,  231 
Anthrospores,  22 
Antiphlogistic  regimen,  103 
Antipyretics,  99 
Antisepsis,  45 

Antiseptic  methods  for  surgical  clean- 
liness, 46 
Antiseptics,  chemical,  24 
Antitoxin  serum  for  tetanus,  189 
Antitoxins,  34,  37 

Antrum,  diseases  and  injuries  of,  713 
of  Highmore,  abscess  of,  128 

inflammation  and  abscess  of,  714 
Antyllus's  operation  for  aneurysm,  318 
Anus,  artificial,  781 

diseases  and  injuries  of,  875 
fissure  of,  892 
imperforate,  888 
prolapse  of,  882 
pruritus  of,  891 
Aorta,  abdominal,  ligation  of,  387.    See 

also  Ligation. 
Apathetic  shock,  206 
Appendiceal  abscess,  127 
Appendicitis,  783 
catarrhal,  787 
diagnosis,  791 
etiology,  785 

foreign  bodies  as  cause  of,  786 
forms  of,  787 
gangrenous,  788 
obliterative,  788 
operation  for,  816-820 
pathology,  785 
simple  parietal,  787 
stercoral,  786 
suppurative,  788 
symptoms,  788-790 
terminations,  790 
treatment,  791-794 
traumatic,  786 
Appendicular  abscess,  127 

colic,  785,  787 
Appendix,  constipation  of,  787 
Arm,  amputation  of,  1043 

hy  circular  method,  1038 
Arterial  infusion  of  saline  fluid,  354 
pyemia,  178 
sclerosis,  309 
transfusion,  354 
Arteries,  inflammation  of,  308 

hgation   of,   in   continuity,  356.     See 

also  Ligation  of  arteries. 
wounds  of,  324 


io86 


INDEX. 


Arteritis,  308 

Arter)',  calcification  of,  309 

clots  formed  after  division  of,  325 
Arthrectomy,  595,  596.     See  also  Eva- 
sion. 
Arthritis,  510,  513 

acute  suppurative,  528 

deformans,  534.     See   also    Osteo-ar- 
thritis. 

gelatiniform  degeneration  in,  515 

gonorrheal,  530 
treatment,  532 

gouty,  533 

infective,  529 

neuropathic,  537 

ossificans,  544 

rheumatic,  532 

rheumatoid,  534.     See  also   Osteo-ar- 
thritis. 

tubercular,  514 

typhoid,  529 
Arthropathy,  tabetic,  537 
Articular  wounds  and  injuries,  540 
Artificial  leech,  83 

respiration,  902 
Ascococci,  21 
Asepsis,  45 
Aseptic  fever,  115 

methods  for  surgical  cleanliness,  45 
Aspiration,  735 

in  thoracotomy,  736 

of  joints,  594 
Aspirator,  594 
Astragalus,  dislocations  of,  583 

excision  of,  608 
Astringents  in  inflammation,  88 
Atheroma,  309 
Atony  of  bladder,  972 
Atrophy  of  bone,  389 

of  muscles,  615 

of  thyroid  gland,  919 
Autointoxication,  34 
Axillary  artery,  364 

ligation  of,  365.    See  also  Ligation. 

Bacilli,  20,  21. 

strepto-,  21 
Bacillus  anthracis  in  blood,  41 

coli  communis,  43 

colon,  43 

divisions  of,  21 

mallei,  43 

of  Eberth,  44 

of  Escherich,  43 

of  glanders,  43 

of  gonorrhea,  41 

of  Lustgarten,  43 

of  malignant  edema,  44 

of  Neisser,  41.     See  also  Gonococcus. 

of  pneumonia,  43 

of  syphilis,  43 

of  typhoid  fever,  44 

as   cause   of   joint-inflammation, 

529 
pyocyaneus,  41 


Bacillus  pyogenes  foetidus,  41 
tetanus,  42 
tuberculosis,  43,  191 
in  sputum,  43 
Bacteria,  17-19 
aerobic,  23 
amotile,  17 
anaerobic,  23 

as  cause  of  peritonitis,  796 
distribution  of,  31 
effects  of  motion,  sunlight,  heat,  and 

cold  upon,  23 
facultative-aerobic,  23 
forms  of,  20 
life-conditions  of,  23 
motile,  17 

multiplication  of,  21 
non-pathogenic,  19 
obligate-aerobic,  23 
parasitic,  19 
pathogenic,  19 
placental  transmission  of,  39 
Bacteriology,  17 
Bacterium  coli  commune,  43 
Balanitis  from  gonorrhea,  1002 

treatment,  1008 
Balanoposthitis  from  gonorrhea,  1002 

treatment,  1008 
Bandages,  927 

American,  of  foot,  930 
Barton's,  931 
Borsch's  eye-,  932 
crossed,  of  angle  of  jaw,  932 

of  both  eyes,  931  ^ 
demigauntlet,  928 
Desault's,  935 
Esmarch's  elastic,  1036 
figure-of-8  of  both  eyes,  931 
of  jaw  and  occiput,  931 
of  thigh  and  pelvis,  933 
gauntlet,  928 
Gibson's,  932 
handkerchief,  937 
oblique,  of  jaw,  932 
of  foot,  930 
plaster-of-Paris,  937 
recurrent,  of  head,  936 

of  stump,  937 
Ribbail's,  930 
Salva's  tliumb,  929 
spica,  of  groin,  933 
of  instep,  930 
of  shoulder,  933 
of  thumb,  929 
spiral,  of  fingers,  928 

of  palm  or  dorsum  of  hand,  928 
reversed,  of  lower  extremities,  929 
of  upper  extremities,  927 
T-,  of  perineum,  937 
Velpeau's,  934 
Barker's  poinl,  location  of,  654 

technic  for  removal  of  appendix,  818 
Barton's  bandage,  931 

fracture,  467 
Basedow's  disease,  921 


INDEX. 


1087 


Bassiiii's  operation  for  femoral  hernia, 
865 
for  inguinal  hernia,  863 
Battle's  sign,  668 
Bed-sore,  148,  164 

Charcot's,  165 
Bees,  stings  of,  227 
Bell's    induction-balance     for    locating 

bullet,  223 
Benzold's  abscess,  678 
Berger's  amputation,  1044 
Bichat's  fissure,  location  of,  650 
Bier's  method  for  leg  amputation,  1049 

for  treating  tuberculosis,  199 
Bigelow's  evacuator,  986 

lithotrite,  987 

operation,  985 
Bigg's  apparatus  for  bunion,  628 
Bile-ducts,  rupture  of,  765 
Bites  of  insects,  227,  228 

of  reptiles,  227 

snake-,  228 
Bladder,  atony  of,  972 

contusion  of,  969 

diseases  and  injuries  of,  965,  969 

exstrophy  of,  969 

female,  growths  in,  994 

hernia  of,  874 

injection  of  air  into,  Brown's  method, 
984 

injury  of,  in  fracture,  442 

nervousness  of,  947 

opening  of,  for  hypertrophy  of  pros- 
tate glan(J,  1027 

operations  on,  981 

rupture  of,  970 

stone  in,  972 

tumors  of,  980 
Blastomycetes,  18 
Blistering,  95 
Blood  in  urine,  tests  for,  942 

transfusion  of,  352 
Blood-clot,  healing  by,  108 
Blood-supply,  cutting  off  of,  83 
Blood-vessels,  development  of,  109 
diseases  and  injuries  of,  302 
in  granulation,  no 
repair  of,  114 
Bloodletting  by  incision,  81 

by  puncture,  81 

in  inflammation,  81,  96 
Bodine's   method  of    intestinal   anasto- 
mosis,   847 

operation  of  colostomy,  851 
Boeckman's  method  for  preparing  cat- 
gut, 55 
Boils,  916 

Aleppo,  917 

blind,  916 
Bond's  splint  in  Colles's  fracture,  471 
Bone,  abscess  of,  392 

actinomycosis  of,  236,  389 

aneurysm  of,  311 

atrophy  of,  389 

caries  of,  390.     See  also  Caries. 


Bone  ferrules,  Senn's,  590 

fractures    of,   404.      See  also   Fract- 
ures. 
head  of,  abscess  of,  136 
hypertrophy  of,  389 
inflammation  of,  389.     See  also    Os- 
teitis. 
necrosis  of,  395.     See  also  Necrosis. 
repair  of,  114 

ring  and  ferrule  applied,  591 
tuberculosis  of,  196,  389 
tumors  of,  389 
Bone-chips,  decalcified,  Senn's,  59 
Bone-felon,  624 
Bone-grafting,  398 
Bones,  affections  of,  in  syphilis,  248 
diseases  and  injuries  of,  389 
excisions  of,  595 
of  skull,  diseases  and  malformations 

of,  655 
operations  on,  585 
Borsch's  eye-bandage,  932 
Rose's  method   for   high    tracheotomy, 

721 
Bottini's    galvanocaustic   operation  for 
hypertrophy  of  prostate  gland, 
1028 
Bowel,  excision  of,  835 
obstruction  of,  775.     See  also  Intes- 
tinal obstruction. 
ulcer  of,  782 
Bow-legs,  635 
Brachial  artery,  362 
ligation  of,  363 
Bracketed   plaster-of-Paris  dressing  of 

fractures,  424,  425 
Brainard's    bone-drills    with    Wyeth's 

handles,  592 
Brain,  abscess  of,  127,  675 
treatment,  677 
compression  of,  diagnosis,  661 
differential,  661,  662 
symptoms,  661 
treatment,  662 
concussion  of,  658 
symptoms,  659 
treatment,  660 
diseases  and  malformations  involving, 

656 
hernia  of,  672 
lacerations  of,  658 
operations  on,  686 
syphilis  of,  252 
traumatic  inflammation  of,  672 

of  membranes  of,  672 
tuberculosis  of,  196 
water  on,  674 
wounds  of,  669 
Brain-disease  from  suppurative  ear-dis- 
ease, 677 
Brain-operations,  technic  of,  689 
Brandt's  operation   of  stomach-reefing 

for  dilated  stomach,  834 
Brasdor's      operation      for      aneurysm, 
320 


io88 


INDEX. 


Braun's  method  of  gastro-enterostomy, 

832 
Breast,  abscess  of,  129,  1056,  1057.    See 
also  Abscess  of  breast. 

cancer  of,  1062.     See  also  Mammary 
gland,  cancer  of. 

diseases  of,  1055 

fissure  of,  1055 

pi-evention  of,  1056 
Brodie's  abscess,  126,  136,  393 

joint,  537 
Bronchus,  foreign  bodies  in,  716 
Brown's   (F.   T.)   method    of    injecting 

air  into  bladder,  984 
Bruises,  perineal,  995 
Brunus'  method  of  upward  extension  in 
shoulder-joint  dislocation,  563 
Bryant's  extension  for  fracture  of  thigh 
in  children,  489 

method  of  colopexy,  883 
Bubo  from  gonorrhea,  treatment,  1008 

indolent,  242 

syphilitic,  242 
Buffy  coat,  78 
Bullet,  conical,  rifle,  217 

cylindricoconoidal,  217 

Dumdum,  221 

forceps,  224 

Lee-Metford,  219 

locating,  in  wound,  223 

Mannlicher,  218 

Mauser,  219 

round,  217 
Bunion,  627 
Burns,  911 
Bursas,  diseases  and  injuries  of,  614 

inflammation  of,  276 
Bursitis,  625 

Butcher's  method  for  excision  of  meta- 
tarsal bone  of  great  toe,  608 
Button  cautery,  95 

suture,  214,  215 

Cachexia,  cancerous,  294 
Calcification  of  artery,  309 
Calculus,  renal,  952 

vesical,  972.    See  also  Vesical  calculus. 
Callus,  416. 
Cancer,  293.     See  also  Carcinoma. 

chimney-sweeps',  266 

colloid,  298 

contagiousness  of,  266 

en  ciiirasse,  1064,  1065 

endothelial,  2B8 

melanotic,  298 

of  breast,  1062.     See  also  Mammaiy 
gland,  cancer  of. 

of  esophagus,  755 

of  mammary  gland,  1062.      See   also 
Mammary  gland. 

of  penis,  1023 

of  rectum,  886 
rest  in,  80 

of    tongue,    differentiation     of,    from 
chancre,  242 


Cancer,  transplantation  of,  294 

treatment,  298 
Cancer-houses,  266,  267 
Cancerous  cachexia,  294 
Cancrum  oris,  163 
Cannon-balls,  wounds  by,  222 
Cannula  a  chemise,  345 
Caput  succedaneum,  658 
Carbolic  acid,  26 
Carbuncle,  917 
anthrax,  230 
Carcinoma,  293 

classification  of,  295 

encephaloid,  297 

glandular,  297 

hematoid,  297 

medullary,  297 

of  lips.  Grant's  operation  for,  746 

of  lower  lip,  746 

of  mammary  gland,  1062 

treatment,  1065 
of  stomach,  769 
of  tongue,  748 
scirrhous,  297 
telangiectatic,  297 
treatment,  298 
Carcinomata,    293.       See     also      Carci- 
noma. 
Cardiac  orifice,  constriction  of,  773 
Caries,  390,  393 
necrotica,  394 
of  lumbar  and  last  dorsal  vertebrae, 

Treves's  operation  for,  593 
sicca,  394  , 

spinal,  699 

treatment,  702 
strumous,  390 
symptoms,  394 
treatment,  395 
tubercular,  390,  394 
Carotid  artery,  common,  371 
ligation  of,  372,  373 
external,  373 
internal,  374 
Carpal  bones,  dislocation  of,  569 
Carpus,  fractures  of,  472 
Cartilages,  floating,  546 
Castration,  1032 
Cataplasm,  92 
Catarrh,  urethral,  chronic,  1003 

venereal,  looi.     See  also   Gonorrhea. 
Catgut,  52 

chromicized,  55 
Fowler's,  54 
preparation  of,  53 

Boeckman's  method,  55 
cumol  method,  54 
formalin  method,  54 
Johnston's  quick  method,  55 
Kronig's  method,  54 
Senn's  method,  54 
tying  of,  56 
Cathartics,  97 

Cathcart's  siphonage  apparatus.  Keen's 
modification  of,  984 


IXDEX. 


1089 


Catheterization  of  ureters,  944 
Cathode  rays,  1068 
Catlin  for  amputation,  1037 
Cautery,  actual,  in  hemorrhage,  335 

button,  95 

Corrigan's,  95 

Paquelin,  in  hemorrhage,  336 
Celiotomy,  813-816 
Cell,  development  of,  into  fibers,  106 
Cell-division,  112 

Cell-proliferation  in  inflammation,  67 
Cellulitis,  183 

diffused,  122 
Cellulocutaneous  erysipelas,  182 
Cementome,  276 
Cephalodynia,  614 
Cerebellum,  tumors  of,  683 
Cerebral  abscess  from  ear-disease,  678 

hemorrhage,  663,  664 

irritability,  659 
"  Chalk-stone,"  533 
Chancre   and   chancroid,   mixed   infec- 
tion, 240 

diagnosis,  241 

differentiation    of,    from     cancer    of 
tongue,  242 
from  chancroid,  241 
from  herpetic  ulceration,  241 
from  phagedena,  242 

hard,  1021 

Hunterian,  240 

redux,  242 

soft,  1020 
Chancroid,  1020 

and  chancre,  mixed  infection,  240 

diflferentiarion  of,  from  chancre,  241 
Charbon,  230.     See  also  Anthrax. 
Charcot's    artery    of    cerebral    hemor- 
rhage, 662 

bed-sore,  165 

disease,  537 

joint,  537 
Charriere's  tourniquet,  1037 
Cheiloplasty  of  lower  lip,  747 
Chemiotaxis,  17 

negative,  35 

positive,  67 
Chest,  contusions  of,  729 

diseases  and  injuries  of,  723 

wounds  of,  730 
Chevne's  operation  for  femoral  hernia, 

865 
Chiene's  lines.  653 

method  for  locating  Rolandic  fissure, 

653 
Chilblain.  915 

Chimney-sweep's  cancer,  266 
Chlorid  of  ethyl  as  fi-eezing  agent,  908 
Chloroform,  administration  of,  897 

anesthetic  state  from,  898 

as  anesthetic,  895 
Chloroma,  286 
Cholecystectomy,  854 
Cholecystenterostomy,  854 
Cholecystotomy,  853 

69 


Choledochotomy,  855 
Cholesteatoma,  273 
Chondromata.  274 
Chopart's  amputation,  1047 
Chordeefrom  gonorrhea,  treatment,  1008 
Choroiditis  in  syphilis,  249 
Cicatricial  tissue,  no 
Cicatrization,  in 
Circulation,  retardation  of,  62 
Circumcision,  1022 
Circumclusion,  332 
Cirsoid  aneurysm,  283 
Clap,  looi.     See  also  Gonorrhea. 
Claret  stains,  282 

Clavicle,  dislocations  of,  555.     See  also 
Dislocations  of  clavicle. 

excision  of.  608 

fractures  of,  444.     See  also  Fractures 
of  clavicle. 
Clavus,  918 
Cleft  palate,  741 

operations  for,  744 
Cloquet's  tabatiere  anatomique,  360 
Clove-hitch   knot  applied  above  wrist, 

563 
Club-foot,  636.     See  also  Talipes. 
Club-hand,  636 
Cocain  hydrochlorate,  908 
Cocainization  of  nerve-trunk,  909 

of  spinal  cord,  911 
Cocain-poisoning,  909 
Cocci,  20 

pyogenic.  21 

wool-sack,  20 
Coccidium  oviforme  as  cause  of  dilata- 
tion of  bile-ducts  in  rabbit,  268 
Coccygodynia,  443 
Coccyx,  fractures  of,  443 
Cock's  operation,  1019 
Cohnheim's  inclusion  theory.  265 
Cold,  effects  of,  914 

Coley's  method  of  treating  sarcoma,  290 
Colic,  appendicular,  785.  787 
Colles's  fracture,  467.     See  also  Fract- 
ures, Colles's. 

law  in  syphilis,  237,  261 
Collins' s' apparatus   for  intravenous  in- 
fusion of  saline  fluid,  353 
Colon  bacillus,  43 
Colopexy.  Bryant's  method,  883 
Colostomy,  inguinal.  850 

lumbar,  853 
Compression,  digital.  333,  334 

in  hemorrhage.  333 

in  inflammation.  88 

of  brain,  660 
Concussion    of   brain,    658.      See    also 
Brain,  concussion  of. 

of  spinal  cord,  709 
Condylomata  in  syphilis,  247 

flat,  246 
Conical  bullet,  rifle,  217 
Continuous  suture,  56,  212,  214 
Contused  wounds,  215 
Contusions,  203 


1090 


INDEX. 


Contusions  of  abdominal  wall,  760. 
See  also  Abdominal  wall,  con- 
tusion of. 

of  bladder,  969 
of  chest,  729 

of  head, 658 

of  lung,  730 

of  muscles,  617 

of  nerves,  644 
of  spinal  cord,  789 
symptoms,  204 
treatment,  204 

with  gangrene,  204 
Cooper's  method  for  reducing  shoulder- 
joint  dislocations,  563 

operation,  388 
Corn,  918 

Corona  venerea,  246 
"  Corpuscle,  educated,"  36 
Corpus  striatum,  tumors  in,  682 
Corradi's  operation  for  aneurysm,  321 
Corrigan's  cautery,  95 
Corrosive  sublimate,  24,  loi 
Cortical  motor  area,  lesions  in,  681 
Costal  cartilages,  dislocation  of,  571 

fractures  of,  438 
Counterirritants  in  inflammation,  94 
Coxa  vara,  640 
Coxitis,  517 

Craniotomy,  linear,  692 
Creolin,  28 
Cretinism,  919 

sporadic,  200 
Cupping,  82 

of  blood-clot,  78 
Cups,  82 

Curling's  ulcer,  782 
Cushing's  right-angled  suture,  821 
Cutaneous  erysipelas,  180 
Cut  throat,  716 
Cyanid  gauze.  Lister's,  58 
Cyanosis  in  anesthesia,  901 
Cylindromata,  288 
Cyrtometer,  Horsley's,  654 
Cystitis,  976 

acute,  976 

chronic,  978 

from  gonorrhea,  treatment,  1008 

rest  in,  80 

tubercular,  treatment,  980 
Cystocele,  858 
Cystomas,  299 
Cystotomy,  991 

for  hypertrophy  of  prostate  gland,  1027 

median,  994 

suprapubic,  992 
Cysts,  299 

dentigerous,  276 

dermoid,  299,  300 

division  of,  299 

extravasation,  299 

exudation-,  299 

hydatid,  299,  301 
of  liver,  803 
of  mammary  gland,  1062 


Cysts,  hydatid,  treatment,  302 

involution,  of  mammary  gland,  1061 

lacteal,  1061 

of  mammary  gland,  1059,  1061.     See 
also  Mammary  glands. 

of  nipple,  1059 

of  pancreas,  811 

retention-,  299 

sebaceous,  300 
Czerny-Lembert  suture,  822,  823 
Czerny's  method  of  tendon-lengthening, 
631 

Dactylitis  in  hereditary  syphilis,  262 
Darier,  psorosperm  of,  268 
Davy's  director,  589 
Decubital  gangrene,  164 
Decubitus,  148,  164 
Defecation-spermatorrhea,  1024 
Degeneration,  cystic,  of  mamma,  1061 

of  muscles,  615 

pulpy,  196 
Delitescence  of  inflammation,  71 
Demigauntlet  bandage,  928 
Dentigerous  cysts,  276 
Deodorizers,  24 
Depression-fracture,  405 
"  Derivative  of  tuberculin,"  200 
Dermatitis,  malignant,  1059 

venenata,  915 
Dermoid  cysts,  299,  300 
Desault's  apparatus,  935 

bandage,  935 

sign,  476 
Diabetic  gangrene,  152,  160 
Diapedesis  in  inflammation,  64,  66 
Diaphoretics,  98 
Diaphragmatic  hernia,  874 
Diaphragm,  rupture  of,  730 
Diastasis,  407 
Diday's   operation   for  webbed  fingers, 

634 
Diffuse  lipoma,  270 
Digestive     tract,    upper,    diseases     and 

injuries  of,  741 
Diplococci,  20 
Diplococcus  pneumoniae,  43 
Disarticulation,  1035 
at  hip-joint,  1053 
at  shoulder-joint,  1043 
of  elbow-joint,  1042 
of  metacarpophalangeal  joint,  1041 
Disease-production,  32 
Diseases  and  injuries  of  abdomen,  760 
of  antrum,  713 
of  bladder,  965,  969 
of  blood-vessels,  302 
of  bones,  389 
of  burspe,  614 

of  chest,  pleura,  and  lungs,  723 
of  genito-urinary  organs,  942 
of  head,  649 
of  heart,  302 
of  kidney,  948 
of  larynx  and  trachea,  715 


IXDEX. 


1 09 1 


Diseases  and  injuries  of  lymphatics,  923 

of  muscles,  614 

of  nerves,  641 

of  nose,  713 

of  penis,  994 

of  prostate,  994 

of  rectum  and  anus,  875 

of  seminal  vesicles,  994 

of  spermatic  cord,  994 

of  tendons,  614 

of  testicles,  994 

of  thyroid  gland,  919 

of  tunica  vaginalis,  994 

of  upper  digestive  tract,  741 

of  ureter,  948 

of  urethra,  994 
and   malformations   involving    brain, 
656 

of  bones  of  skull,  655 
of  bones,  3S9 
of  breast,  1055 
of  head,  649 
of  joints,  510 
of  mouth,  741 
of  nails,  915 
of  skin,  915 
of  tongue,  741 
Disinfection  of  instruments,  50 

Schimmelbusch's  apparatus  for,  50 
Dislocations,  547 

at    inferior    radio-ulnar   articulation, 

569 
at   superior   tibiofibular   articulation, 

581 
bilateral,  548 
complete,  547 
complicated,  547 
compound,  547 
congenital,  548 
consecutive,  548 

distinguishing  of,  from  fractures,  413 
double,  548 
habitual,  548 
incomplete,  547 
Monteggia's,  577 
Nelaton's,  582 
occurring  with  fracture,  reduction  of, 

422 
of  ankle-joint,  581,  582 
of  astragalus,  583 
of  carpal  bones,  569 
of  clavicle,  555 

acromial  end  of,  556 

Rhoads's  apparatus  for,  557 

sternal  end  of,  555 

upward,  556 
of  costal  cartilages,  571 
of  elbow-joint,  564 

both  bones,  backward,  564 
forward,  465 
lateral,  566 

reduction,  565 
of  fem.ur,  571 

downward,  into  obturator  foramen, 
575 


Dislocations    of   femur,    head    of,    with 
fracture  of  shaft,  577 

into  sciatic  notch,  574 

ischial,  577 

Monteggia's,  577 

on  dorsum  of  ilium,  572 

on  pubis,  576 

perineal,  577 

subspinous,  577 

suprapubic,  577 

supraspinous,  576 

with  catching  up   of  sciatic  nerve 
upon  reduction,  577 
of  fibula,  581 
of  hip,  anomalous,  576 
of  hip-joint,  571.     See  also  Disloca- 
tions of  femur. 

congenital,  operations  for,  613 
of  humerus,   557.     See  also  Disloca- 
tions of  shotilder-Joitit. 
of  kidney,  949 
of  knee-joint,  578,  579 
of  lower  jaw,  553 
of  metacarpal  bones,  569 
of  metatarsal  bones,  584 
of     metacarpophalangeal     joint     of 

thumb,  569 
of  muscles,  619 
of  patella,  579,  580 
of  phalanges,  570,  584 
of  radius,  566,  567 
of  ribs,  571 

of  scapula,  lower  angle  of,  557 
of  semilunar  cartilages  of  knee,  580 
of  shoulder-joint,  557 

diagnosis,  561 

partial,  560 

Pick's  table  of,  560 

reduction  by  extension,  562 

subcoracoid,  558 

symptoms,  559 

treatment,  561 

Kocher's  method,  561 
Smith's  (Henry  H.)  method,  562 
of  spine,  710 
of  sternum,  571 
of  tarsal  bones,  584 
of  tendons,  619 
of  ulna,  566 

of  ulnar  nerve  at  elbow,  644 
of  wrist,  568 

deformity  in,  568 
old,  548 
partial,  547 
pathological,  548 
pelvic,  571 
primitive,  547 
recent,  548 
relapsing,  548 
secondary,  547 
simple,  547 
single,  548 
spontaneous,  548 
subastragaloid,  583 
traumatic,  547,  549 


1092 


INDEX. 


Dislocations,  traumatic,  causes,  549 
compound,  treatment,  552 
diagnosis,  551 
old,  treatment,  553 
pathological  conditions  in,  549 
simple,  treatment,  551 
special,  553 
symptoms,  550 
treatment,  551 
unilateral,  548 
Displacement  in  plastic  surgery,  939 
Dissection-wounds,  226 
Diuretics,  98 

Diverticula  of  esophagus,  757 
Dorsalis  pedis  artery,  377 
Douche,  Scotch,  90 
Drainage,  58 
Drainage-tubes,  58 

for  abscess  requiring  irrigation,  134 
Dressings,  57 
fixed,  937 
gauze,  57 
Lautenschlager's  steam-sterilizer  for, 

57 

silicate-of-sodium,  938         - 
Dropsy,  511 

of  joint,  531 
Drop-wrist,  454 
Dumdum  bullet,  221 
Dunham's   apparatus   for   fractures    of 

thigh  in  children,  489,  490 
Duodenostomy,  834 
Dupuytren's  aneurysm-needles,  356 

contraction,  633 

fracture,  582 

operation  for  amputation  at  shoulder- 
joint,  1044 

suture,  84 
Dura  mater,  hematoma  of,  673 
Duret's  operation,  834 

Ear,  affections  of,  in  syphilis,  248 

hemorrhage  from,  343 
Eaf-disease,  cerebral  abscess  from,  678 

suppurative,  brain-disease  from,  677 
Eberth's  bacillus,  44 
Ecchondroses,  274 
Ecchymosis,  203 
Ecthyma,  246 
Ectopia  vesica,  969 

Edebohls's  method  of  nephrotomy,  960 
Edema  from  fractures,  treatment,  421, 
422 

malignant,  226 
bacillus  of,  44 

of  glottis,  715 

of  larynx,  715 
"  Educated  corpuscle,"  36 
Effusions,  purulent,  134 
Elbow,  miners',  626 
Elbow-joint,  disarticulation  of,  1042 

disease,  527 

dislocations  of,  564 

excision  of,  600 

fractures  in,  458 


Electricity,  effects  of  artificial  currents, 
1080 

injuries  by,  1078 
Electrohemostasis  in  hemorrhage,  336 
Electrolysis  for  treatment  of  aneurysm, 

321 
Elephantiasis,  924 

Arabum,  924 
Elliptical  method  of  amputation,  1039 
Embolism,  170 

air-,  173 

fat-,  172 

symptoms,  171 

treatment,  171 
Embolus  in  pulmonary  artery,  171 
Emetics,  100 

Emphysema,  gangrenous,  158,  226 
Emprosthotonos  in  tetanus,  185 
Empyema,  129,  724 

chronic,  725 

treatment,  725 
Encephalitis,  674 
Encephalocele,  656 
Enchondromata,  274 
Endarteritis,  obliterative,  309 

syphilitic,  252 
Endospore,  22 
Endotheliomata,  288 
Endspore,  22 
Enterectomy,  835 

Senn's   modification   of   Jobert's   in- 
vagination method,  837 

use  of  Murphy's  button  in,  837 
Enteritis,  rest  in,  80 
Entero-anastomosis,  Senn's,  843 
Enterocele,  858 
Entero-epiplocele,  858 
Enteroptosis,  794 
Enterorrhaphy,  820-823 

circular,  835,  838 

Harris's  method,  839,  840 
Kocher's  method,  839 
Mayo-Robson's  method,  839 
suture  of  mesentery  after,  841 
use  of  Halsted's  cylinder  in,  841 
Enterostenosis,  775 
Enterostomy,  850 
Epidermization,  iii 
Epididymis,  encysted  hydrocele  of,  1034 
Epididymitis,  1032 

in  gonorrhea,  1002 
treatment,  1009 

in  syphilis,  249 
Epigastric  hernia,  873 
Epiglottis,  closure  of,  in  anesthesia,  902 
Epilepsy  in  syphilis,  252 

Jacksonian,  681 

treatment,  operative,  684-686 
Epiphyseal  separation,  407 
Epiphysitis,  acute,  399 
symptoms,  401 
treatment,  402 
Epiplocele,  858 
Epispadias,  1019 
Epistaxis,  plugging  nares  for,  342 


IXDEX. 


1093 


Epithelioma,  cylindrical-ceHed,  296 

squamous-celled,  295 
Epitheliomata,  295 
Epulides.  fibrous,  271 
Epulis,  fibrous,  272 
Equinia,  234 
Erasion,  595 

of  knee-joint,  596 
Erethistic  ulcer,  147 
Ergotism,  gangrene  from,  161 
Erichsen's  ligature,  method  of  applying, 

283 
Eruptions  in  sj.'philis,  forms  of,  244 
Er\-sipelas,  179 

as  cure  for  sarcomata,  290 

cellulocutaneous,  182 

clinical,  180 

cutaneous,  180 

forms  of,  180 

phlegmonous,  182 

streptococcus  of,  41 
Erythema  of  syphilis,  245 
Escherich's  bacillus,  43 
Esmarch's  cooling  coil,  87 

elastic  bandage,  1036 

splint  for  treatment  after  excision  of 
elbow-joint,  601 
interrupted,  603 
Esophageal  instruments,  753 
Esophagismus,  756 
Esophagus,  cancer  of,  755 

diseases  of,  741 

diverticula  of,  757 

foreign  bodies  in,  758 

injuries  of,  757 

strictures  of,  752 
spasmodic,  756 
treatment,  753-755 
Estlander's  operation,  738 
Ether,  administration  of,  898 

anesthetic  state  from,  898 

as  anesthetic,  895 
Ether-inhaler,  AUis's,  898 
Ethyl  bromid,  906 
Ethyl-spray  as  freezing-agent,  908 
Eucain  hydrochlorate,  910 
Europhen,  30 
Evacuation,    spontaneous,    of    abscess, 

124 
Evacuator,  Bigelow's,  986 

Thompson's,  9S8 
Excision  of  ankle-joint,  606 

of  astragalus,  608 

of  bones,  595 

of  clavicle.  608 

of  elbow-joint,  600 

of  hip-joint.  603 

by  anterior  incision,  604 
by  incision  of  Gross,  605 
by  lateral  incision,  604 

of  joints,  595 

of  knee-joint,  605 

of  lower  jaw,  612 

of  metacarpal  bones,  603 

of  metatarsal  bone  of  great  toe,  608 


Excision  of  metatarsophalangeal  articu- 
lation of  great  toe,  608 
of  OS  calcis,  607 
of  phalanges,  603 
of  rib,  609 
of  scapula,  609 
of  shoulder-joint,  597 
by  anterior  incision,  599 
by  deltoid  flap,  599 
partial,  598 
Senn's  method,  600 
of  testicle,  1032 

of  upper  jaw,  complete,  610-612 
of  wrist-joint,  601 
Lister's  method,  601 
Excur\-ation,  698 
Exfoliation,  396 
Exophthalmic  goiter,  921 
Exostosis,  275 

subungual,  276 
Exploratory  puncture    of  pleural   sac, 

735 
Exstrophy  of  bladder,  969 
Extradural  abscess,  679 
hemorrhage,  662,  663 
Extravasation,  203 
Extravasation-cysts,  299 
Exuberant  ulcer,  146 
Exudation-cysts,  299 
Eye,  affections  of,  in  syphilis,  249 

Fabricius'S     operation     for     femoral 

hernia,  865 
Facial  artery,  375 
Facultative  aerobic  bacteria,  23 
False  joint,  417 
Farcy,  234 
Farcy-buds,  235 
Fasciotomy,   subcutaneous,   of  plantar 

fascia,  630 
Fat-embolism,  172 
Fat-hernia,  270 
Fecal  fistula,  781 

Senn's  operation  for,  850 
Feet,  senile  gangrene  of,  154 
Fell-O'Dwyer  apparatus,  729 
Felon,  623 

bone.  624 

deep,  624 

incisions  for,  625 

superficial,  623 

suppurative,  129 
Femoral  arteiy,  382 
ligation  of,  383 

hernia,  873 
Femur,  dislocations  of,  571 

fractures  of,  473 
Fergusson's  operation  for  cleft  palate, 

745 
for  varix  of  leg,  349 
Ferrules,  bone,  Senn's,  590 
Fever,  aseptic,  115 

essential  phenomena  of,  115 
hectic,  117,  127 
malarial,  117 


I094 


INDEX. 


Fever  of  iodoform  absorption,  117 

of  tension,  117 

scarlet,  surgical,  118 

splenic,  230.     See  also  Anthrax. 

suppurative,  117,  126 

surgical,  115,  116 

syphilitic,  243 

traumatic,  115,  116 

urethral,  1016 

urinary,  1017 
Fibers,  cells  developing  into,  106 
Fibro-adenoma  of  mammary  gland,  1060 
Fibroblasts,  68 
Fibro-fatty  tumor,  269 
Fibroid,  uterine,  272,  278 
Fibroma    of    mammary    gland,    cystic, 

1061 
Fibromata,  271 

nasopharyngeal,  271 

treatment,  273 
Fibrosarcoma,  287 
Fibrous  epulides,  271 

epulis,  272 
Fibula,  dislocations  of,  581 

fractures  of,  504 
Figure-of-8  of  both  eyes,  931 

of  jaw  and  occiput,  931 

of  thigh  and  pelvis,  933 
Fingers,  amputation  of,  1040 
Fissure,  405 

intraparietal,  location  of,  653 

of  anus,  892 

of  Bichat,  location  of,  650 

of  breast,  1055 

of  Rolando,  location  of,  651,  653 

of  Sylvius,  location  of,  652 
Fistula,  140,  149 

fecal,  781.     See  also  Fecal  fistula. 

in  ano,  889 

operation  for,  890 

treatment,  150 
Flail-joints,  640 

Flap  method  of  amputation,  1039 
Flat-foot,  637 
Floating  cartilages,  546 

kidney,  948 
Fluoroscope,  Edison's,  1070 
Foot,  amputation  of,  1045 

fracture  of  bones  of,  508 
Foramen  of  Winslow,  hernia  into,  874 
Forbes's  lithotrite,  987 
Forceps,  bullet-,  224 

hemostatic,  329 

Laplace's,  for  intestinal  anastomosis, 
842 

vesical,  Thompson's,  992 
Ford's  stitch,  822 

suture,  213 
Forearm,  amputation  through,  1042 

and  hands,  sterilization  of,  48 
Formaldehyd,  30 
Formalin,  30 

method  for  preparing  catgut,  54 
Formalin-gelatin,  30 
Formic  aldehyd,  30 


Fort's  electrolysis  method  for  stricture 

of  urethra,  1015 
Fowler's  catgut,  54 

operation  for  inguinal  hernia,  864 
Fox's  apparatus  for  fracture  of  clavicle, 

446 
Fracture-box  in  fractures  of  leg,  503 
Fracture-dislocations  of  spine,  710 
Fracture-hook  applied  at  base  of  acro- 
mion process,  422 
inserted  in  displaced  fragment,  422 
of  McBurney  and  Dowd,  422 
Fractures,  404 
amputation  for,  423 
Barton's,  467 
bent,  405 
bracketed  plaster-of-Paris  dressing  in, 

424, 425 
by  contrecoup,  407 
capillary,  405 
causes,  407,  408 
Colles's,  467 

Bond's  splint  in,  471 
symptoms,  468 
treatment,  470 
comminuted,  406 
complete,  405 
complicated,  404 
complications  in,  415 
prevention  of,  421 
treatment,  421 
compound,  404 

amputation  for,  423 
repair  of,  417 
treatment,  423 
consequences  of,  415 
counterextension  in,  418 
crepitus  or  crepitation  in,  412 
cuneated,  406 
cuneiform,  406 
delayed  union  in,  417 
dentate,  406 
depression-,  405 
diagnosis,  413 

by  ;ir-ray,  413,  415 
direct,  407 
dislocation  occurring  with,  reduction 

of,  422' 
displacements  in,  varieties  of,  410 
distinguishing   of,   from    dislocations, 

413 
Dupuytren's,  582 
en  coin,  406 
en  rave,  406 
en  V,  406 
extension  in,  418 
extracapsular,  407 
extravasation  of  blood  in,  411 
false  joint  in,  417 
fenestrated    plaster-of-Paris    dressing 

in,  424 
fibrous  union  in,  417 
fissured,  405 
.green-stick,  405 
hair,  405 


INDEX. 


1095 


Fractures,  helicoidal,  407 
hickory-stick,  405 
impacted,  406 
incomplete,  405 
indirect,  407 

in  elbow-joint,  anterior  angular  splint 
for,  458,  459 

Frazier's    modification    of   Jones's 
dressing  for,  461 

treatment,  459-462 
injury  of  bladder  in,  442 

of  urethra  in,  442 
intra-articular,  407 
intracapsular,  407 
intra-uterine,  407 
ligamentous  union  in,  417 
linear,  405 
longitudinal,  405 
loss  of  function  in,  411 
massage  in,  419 
membranous  union  in,  417 
non-union  of,  417 
oblique,  405 

spiroide,  406 
of  acetabulum,  442 

brim  of,  478 
of  bones  of  foot,  508 
of  carpus,  472 
of  clavicle,  444 

at  acromial  end,  447 

at  sternal  end,  448 

Fox's  apparatus  for,  446 

in  shaft,  444 

Moore's  dressing  in,  446 

Sayre's    adhesive-plaster    dressing 
for,  446 
of  coccyx,  443 
of  costal  cartilages,  438 
of  false  pelvis,  440 
of  femur,  473  ~ 

above  condyles,  490 

at  base  of  neck,  482 

at  lower  epiphysis,  492 

at  upper  epiphysis  of  femoral  head, 
483 

extracapsular,  482 

diagnosis,  differential,  from  intra- 
capsular, 477 

great  trochanter  of,  483 

intracapsular,  474-482 
diagnosis,  477 
prognosis,  478 
treatment,  478 

in  upper  third,  dressing  of,  486 

longitudinal,  492 

separating  either  condyle,  492 

separation    of    epiphysis    of    great 
trochanter,  484 

shaft  of,  484 

upper  extremity  of,  474 
of  fibula,  504 
of  forearm,  both  bones  of,  splints  for, 

465 
shafts  of,  467 
of  hip,  intracapsular,  474 


Fractures  of  humerus,  449 

anatomical  neck  of,  449 

at  base  of  condyles  of,  457 

at  lower  epiphysis,  462 

at  upper  epiphysis,  453 

condyles  of,  apparatus  for  any  point 
above,  452 

external  condyle  of,  456 

head  of,  453 

inner  epicondyle,  456 

internal  condyle,  456 

lower  extremity  of,  455 

outer  epicondyle,  456 

shaft  of,  454 

surgical  neck  of,  451 

T-fractures,  458 

upper  extremity  of,  449 
of  hyoid  bone,  433 
of  inferior  maxillary  bone,  431-433 
of  lacrymal  bone,  428 
of  laryngeal  cartilages,  434 
of  leg,  502 

both  bones  of,  507 

cradle     to     keep     clothing     from, 
480 

fracture-box  in,  503 
of  malar  bone,  430 
of  metacarpus,  473 
of  metatarsal  bones,  509 
of  nasal  bones,  426 

Jones's  nasal  splint  in,  428 
Mason  pin  in,  428 
of  patella,  492 

badly  united,  501 

by  direct  force,  499 

by  muscular  action,  492 
mechanism  of,  493 

transverse,  495 
wiring  of,  496-499 

treatment,  operative,  593 

ununited,  501 

wired,  500 

wiring  of,  593 
of  pelvis,  440 
of  penis,  1022 
of  phalanges,  473 
of  radius,  465-472 
of  sacrum,  442 
of  scapula,  448 
of  skull,  664 
of  spine,  710 
of  sternum,  438 
of  superior  maxillary  bone,  429 
of  thigh  in  children,  4S8-490 

Bryant's  extension  for,  489 
of  tibia,  502 
of  toes,  509 
of  true  pelvis,  441 
of  ulna,  462 

and  radius  near  wrist,  472 
of  zygomatic  arch,  430 
overlapping  of  fragments  in,  411 
overriding  of  fragments  in,  411 
par  irradiation,  407 
pathological,  406 


1096 


INDEX. 


Fractures,  Pott's,  505 
radish,  406 

recent,  treatment,  operative,  590 
repair  of,  415 
secondary,  406 
simple,  404 

repair  of,  415 
special,  426 
spiral,  407 
splinter-,  405 
spontaneous,  406 
sprain-,  405 
stellate,  407 
strain-,  405 
symptoms,  410 
toothed,  406 
torsion,  407 
transverse,  406 
treatment,  418 
ambulatory,  420 
amputation,  423 
T-shaped,  406 

union  of,  delayed,  treatment,  425 
vicious,  17,  426 

osteotomy  for,  589 
ununited,  406,  417 

Parkhill's  clamp  for,  426 
treatment,  425 

operative,  592 
wiring  of,  592 
varieties  of,  404 
V-shaped,  406 
wedge-shaped,  406 
willow,  405 
with  crushing,  406 
with  penetration,  406 
;ir-rays  in,  1077 
Frank's  method  for  gastrostomy,  830 
Frazier's  modification  of  Jones's  dress- 
ing for  injuries  in  elbow-joint, 
461 
Freezing  as  local  anesthetic,  906 
French  olivary  gum  catheter,  968 
Frequency  of  micturition,  947 
Frontal  sinus,  distention  and  abscess  of, 

715 
trephining  of,  688 
Frost-bite,  gangrene  from,  162 
Fulminating  gangrene,  158 
Fungous  ulcer,  146 
Fungus  cerebri,  672 

hsematodes,  286 

of  testicle,  197 
Furuncle,  916 
Furunculosis,  916 

Galactocele,  1061 
Gall-bladder,  802 

rupture  of,  765 
Gall-stones,  806 

treatment,  809 
Gait's  conical  trephine,  687 
Ganglia,  622 
Gangrene,  150 

acute,  156 


Gangrene,  chronic,  157 

classification,  151 

contusion  with,  204 

decubital,  164 

diabetic,  152,  160 

dry,  151,  152 

foudroyante,  158 

from  ergotism,  161 

from  fracture,  treatment  of,  421 

from  frost-bite,  162 

fulminating,  158 

hospital,  151,  159 

line  of  demarcation  in,  153 

microbic,  151 
acute,  158 

moist,  151,  156 

of  lung, 733 

of  penis,  1023 

postfebrile,  166 

Pott's,  153 

Raynaud's,  152,  159 

treatment,  160 

senile,  153 

special  forms,  159 

spreading  traumatic,  158 

symmetrical,  152,  159 

when  to  amputate  for,  167 

jr-ray,  1071,  1072 
Gangrenous  emphysema,  158,  226 

masses,  163 
Gant's  operation,  587,  588 
Garel's  sign,  128 

Gasserian  ganglion,  removal  of,  648 
Gastrectomy,  total,  827 
Gastro-enterostomy,  830 

anterior,  831 

Braun's  method,  832 

by  Murphy  button,  833 

Jaboulay's  method,  832 

Kocher's  method,  831 

posterior,  833 

Senn's  method,  831 

Wolfler-Gucke  method,  833 
Gastrogastrostomy,  834 
Gastro-jejunostomy,  830.    See  also  Gas- 

tro-e7itcrostomy. 
Gastropexy,  834 
Gastroplication,  834 
Gastrostomy,  828 

Frank's  method,  830 

Kader's  method,  829 

Senn's  (Emanuel)  operation  for,  830 

Witzel's  method,  829 
Gastrotomy,  827 
Gauntlet  bandage,  928 
Gauze,  cyanid,  Lister's,  58 

dressings,  57 

iodoform,  57 

sterilized,  57 
Gelsemium,  97 

Genito-urinary  organs,  diseases  and  in- 
juries of,  942 
Genu  valgum,  635 

osteotomy  for,  585 

varum,  635 


INDEX. 


1097 


Germicides,  24 

Gerster's  plan   to  diminish  swelling  m 

fracture  of  humerus,  456 
Gibson's  bandage,  932 
Girdner's  telephonic  probe,  223 
Glanders,  234 

bacillus  of,  43 
Glandule  Pleiades,  243 
Glandular  carcinoma,  297 
Gleet,  1003 

Glenard's  disease,  794 
Gliomata,  281 
Glottis,  edema  of,  715 

scalds  of,  914 
Glover's  stitch,  56 
Gloves,  use  of,  in  operations,  49 
Gluteal  artery,  385 
ligation  of,  386 
hernia,  874 
Glutol,  31 
Goiter,  920 

exophthalmic,  921 
pulsating,  921 
Gonococcus,  41 
Gonorrhea,  looi 
abortive,  1003 
acute  inflammatory,  symptoms,  looi 

treatment,  1004,  1007 
bacillus  of,  41 
black,  looi 
catarrhal,  1003 
complications  of  1002 
in  female,  loio 
irrigation  of  urethra  in,  1004 
irritadve,  1003 
of  rectum,  loio 
subacute,  1003 
uterine,  loio 
Gonorrheal  ophthalmia,  treatment,  1009 
Gouley's  divulsor,  1016 
tunnelled  catheter,  967 
whalebone  guides,  967 
Gout,  rheumatic,  534 
Granny  knot,  method  of  tymg,  330 
Grant's  operation  for  carcinoma  of  hp, 

746 
Granulation,  blood-vessels  m,  no 

healing  by,  109 
Granulation-tissue,  125 
Graves's  disease,  921 
Grith's  operation  for  amputation  through 

femoral  condyles,  105 1 
Gross's  incision,  605 

urethral  dilator,  1015 
Gross's  (S.W.)  exploratory  urethrotome, 

1015 
Growths,  new,  of  inflammation,  71 
Guiteras's  plan  for  diagnosis  of  stricture 

of  urethra,  1012 
Gum  catheters,  curved,  968 
Gumma  in  tertiary  syphilis,  251 
Gummata,  tubercular,  194    . 
Gunshot  wounds,  217 

amputation  for,  225 

hemorrhage  from,  343 


Gunshot  wounds,  hemorrhage   in,  222, 
224 

of  abdomen,  768 

of  arteries,  326 

of  head,  670 

prevention  of  infection  of,  225 

probing  for  bullet  in,  223 

symptoms,  222 

treatment,  222 
Gussenbauer's  suture,  823 
Guthrie's  rule,  337 


Hagedorn's  needles,  331 

Hair,  affections  of,  in  syphilis,  248 

Hallux  valgus,  639 

osteotomy  for,  589 
Halsted  suture,  56.  822 
Halsted's  operation  for  cancer  of  breast, 
1065-1067 
for  inguinal  hernia,  863 
for  lateral  anastomosis,  845,  846 
subcuticular  suture,  213,  214 
Hamilton's  bandage  in  fractures  of  in- 
ferior maxillary  bone,  432 
bone-drills,  592 
Hammer-toe,  639 
Hancock's    operation    for   excision    ot 

'        knee-joint,  607 
Hand,  amputation  of,  1040 
Hand  and  forearms,  sterili'zation  of,  48 
Handkerchief  bandages,  937 
Harelip,  741 
double,  743 
operation  for,  742 
Malgaigne's,  742 
Miraidt's,  743 
single,  742 
Harris's  catheterization  of  ureters,  945 
double  catheter,  945 
method    of    circular    enterorrhaphy, 

839.  840  . 

Hartley's   osteoplastic  flap  m  removal. 

of  Gasserian  ganglion,  648 
Head,  contusion  of,  658 

diseases  and  injuries  of  649 

gunshot  wounds  of,  670 

injuries  of,  658 
Healing  by  blood-clot,  108 

by  first  intention,  105,  107 

by  granulation,  109 

by  second  intendon,  109 

by  third  intention,  112 
Heart,  diseases  and  injuries  of,  302 

wounds  and  injuries  of,  302 
Heart-cavity,  tapping  of  348 
Heat  as  a  germicide,  31 

in  inflammation,  87,  90-93 
Heberden's  nodosities,  535 
Hectic  fever,  117,  127 
Heineke-Mikulicz  operation,  824 
Heller's  test  for  blood  in  urine,  943 
"  Helpless    eversion"    in    intracapsular 

fracture  of  femur,  476 
Hemangiomata,  282 
Hematemesis,  34S 


1098 


INDEX 


Hematocele,  1034 
Hematoma,  203,  658 

of  dura  mater,  673 
Hematomyelia,  709 
Hematuria,  942 

renal,  944 
Hemophilia,  355 
Hemoptysis,  346 
Hemorrhage,  326 

actual  cautery  in,  335 

acupressure  in,  332 

after  lateral  lithotomy,  344 

arrest  of,  by  suture-ligature,  331 

arterial,  336 

capillary,  326,  341 

cautery  in,  actual,  335 
Paquelin's,  336 

cerebral,  663,  664 

compression  in,  333 

consecutive,  346 

electrohematosis  in,  336 

elevation  in,  333 

extradural,  340,  662,  663 

extramedullary  spinal,  340 

forced  flexion  in,  335 

from  abdominal  section  of  female  pel- 
vis, 341 

from  cerebral  sinus,  340 

from  cut  urethral  meatus,  344 

from  diploe,  339 

from  ear,  343 

from  femoral  vein,  340 

from  gunshot  wounds,  222,  224,  343 

from  intercostal  artery,  339 

from  internal  mammary  artery,  339 

from  large  bowel,  346 

from  leech-bite,  343 

from  lung,  346 

from  nose,  342 

from  palmar  arch,  337 

from  prostate,  344,  946 

from  punctured  wounds,  339 

from  ruptured  varicose  vein,  341 

from  shock,  346 

from  small  bowel,  345 

from  stomach,  345 

from  tooth-socket,  340 

from  veins,  337,  339 

from  vessel  in  bony  canal,  339 

from  wound  of  extremity,  338 

Guthrie's  rule  in,  337 

hemostatic  agents  in,  328 

in  amputation,  1035 

injections  for,  342 

intercurrent,  346 

intermediate,  346 

into  pancreas,  810 

intra-abdominal,  341 

intracranial,  662 

ligation  in,  328 

method  of  controlling  by  ligature,  331 

muscse  volitantes  in,  327 

Paquelin's  cautery  in,  336 

pressure  in,  342 

primary,  338 


Hemorrhage,  primary,  golden  rules  for 
procedure  in,  336-346 

reactionary,  346 

rectal,  343 

recurrent,  346 

renal,  345 

secondary,  347 

styptics  in,  335 

subcutaneous,  326,  343 

subdural,  663,  664 

tinnitus  aurium  in,  327 

torsion  in,  332 

tourniquet  in,  333 

umbilical,  343 

urethral,  946 

uterine,  345 

vaginal,  345 

venous,  326 

vesical,  344,  946 
Hemorrhagic  diathesis,  355 

infarct,  171 

ulcer,  148 
Hemorrhoids,  306,  878 

application  of  ligature  for,  882 

arterial,  880 

capillary,  879 

external,  878,  879 

extirpation  of,  881 

internal,  878 
symptoms,  880 
treatment,  880 

mixed,  878 

venous,  879 
Hemostatic  agents,  328 

forceps,  329 
Hepatoptosis,  805 
Hepatotomy,  transthoracic,  131 
Hereditary  syphilis,  238,  260 
Hernia,  abdominal,  857 

causes,  858 

congenital,  Macewen's  operation  for, 
862 

diaphragmatic,  874 

epigastric,  873 

fat-,  270 

femoral,  873 

Bassini's  operation  for,  865 
Cheyne's  operation  for,  865 
Fabricius's  operation  for,  865 

gluteal,  874 

hydrocele  of,  1034 

incarcerated,  866 

infantile,  873 

inflamed,  866 

inguinal,  872 

Bassini's  operation  for,  863 
Fowler's  operation  for,  864 
Halsted's  operation  for,  863 
Kocher's  operation  for,  864 
Macewen's  operation  for,  861 

into  foramen  of  Winslow,  874 

irreducible,  866 

labial,  872 

Lannelongue's  method  for  treatment 
of,  861 


INDEX. 


1099 


Hernia,  lumbar,  874 
obstructed,  866 
obturator,  874 
of  bladder,  874 
of  brain,  672 
of  lung, 731 
of  muscle,  619 
perineal,  874 
preperitoneal,  874 
pudendal,  874 
reducible,  859 

Rokintansky's  diverticular,  874 
sciatic,  874 
scrotal,  872 
strangulated,  867 
treatment,  869 
umbilical,  873 

radical  cure  of,  865 
vaginal,  874 
varieties  of  872 
ventral,  873 
Hernia-director,  hinged,  861 
Hernia-needles,  861 
Herniotomy,  870-872 
Herpetic  ulceration,  differentiation  of, 

from  chancre,  241 
Heurteloup's  artificial  leech,  83 
Hey,  internal  derangement  of,  580 
Hey's  method  for  amputation  at  tarso- 
metatarsal articulation,  1046 
Highmore,  antrum  of,  abscess  of,  128 
Hip,  abscess  of  518 
Hip-disease,  516 

Hip-joint,  disarticulation  at,  1053 
disease,  516 
dislocations  of  571 
excision  of,  603 
osteo-arthritis  of  536 
Hodgen's    apparatus    for   fractures    of 

thigh,  487 
Hodgkins  disease,  924 
Hoffa's  operation,  613 
Hollow-foot,  638 
Horsley's  cyrtometer,  654 

method  of  intestinal  anastomosis,  846 
Hospital  gangrene,  151,  159 
Hot-air  apparatus,  Sprague,  513,  514 
Housemaid's  knee,  626 
Humerus,  dislocations  of,  557 
fractures  of,  449 
subluxation  of,  619 
Hunterian  chancre,  240 
Hunter's  canal,  382 

derivative  of  tuberculin,  200 
operation  for  aneurysm,  318 
Hutchinson's  knee-joint  splint,  525 

teeth  in  hereditary  syphilis,  262 
Hydatid  cysts,  299,  301 
of  liver,  803 

of  mammary  gland,  1062 
treatment,  302 
fremitus,  301,  803 
toxemia,  302,  803 
Hydrarthrosis,  531 
Hydrencephalocele,  657 


Hydrocele,  1033,  1034 
Hydrocephalus,  657 

acquired,  657 

acute,  657,  674 

chronic,  657 

congenital,  657 

external,  657 

internal,  657 
Hydrogen  peroxid,  28 
Hydronephrosis,  279,  956 
Hydrophobia,  232 

Pasteur  treatment  of,  233 
Hydrops  articuli,  511 
Hydrorrhachitis,  693 
Hygroma,  299 

Hyoidbone,  fractures  of,  433 
Hyperemia,  active,  61 
Hypertrophy  of  thyroid  gland,  919 

of  bone,  389 

of  muscles,  615 

of  prostate  gland,  1025 
prostatectomy  for,  1028 
treatment,  1026-1030 
Hyphomycetes,  18 
Hypnotics,  99 
Hypospadias,  1019 
Hysteria,  traumatic,  707 
Hysterical  joint,  537 

ICHTHYOL  in  inflammation,  89 

Ileus,  775 

Iliac  abscess,  136,  784 

arteries,  384 
ligation  of,  384 
Immediate  union,  106 
Immunity,  durability  of,  36 

from  syphilis,  237 
Imperforate  anus,  888 
Impetigo,  246 
Implantation,  849 
Incarcerated  hernia,  866 
Incised  wounds,  211 
Incision,  blood-letting  by,  81 

radial,  601 

ulnar,  602 
Inclusion  theory  of  Cohnheim,  265 
Indolent  bubo,  242 

ulcer,  147 
Induction-balance  of  Bell  for  locating 

bullet,  223 
Infantile  hernia,  873 

scurvy,  202 
Infarct,  hemorrhagic,  171 
Infarction,  170 
Infection  in  utero,  261 

mixed, 38 

septic,  176 
Infective  sinus-thrombosis,  679 
Inferior  carotid  triangle,  370 
ligation  in,  372 

thyroid  artery,  368 
ligation  of,  368 
Infiltration,  purulent,  122 
Infiltration-anesthesia,  910 
Inflammation,  60-105 


1  lOO 


INDEX. 


Inflammation,  acute,  symptoms,  72 

treatment,  79 
arterial  sedatives  in,  97 
as  cause  of  tumors,  266 
astringents  in,  88 
blood-letting  in,  81,  96 
causes,  71 

cell-proliferation  in,  67 
changes  in  perivascular  tissue  in,  67 
chronic,  78 

circulatory  changes  in,  60 
classification  of,  69 
cleanliness  in,  104 
cold  in,  84 
compression  in,  88 
counterirritants  in,  94 
cupping  in,  82 
delitescence  of,  71 
depletion  in,  81  • 

derangement  of  absorbents  in,  jj 

of  secretions  in,  tj 
diapedesis  in,  64,  66 
diet  in,  103 

dilatation  of  vessels  in,  63 
discoloration  in,  75 
disordered  function  in,  77 
extension  of,  71 
fomentation  in,  90 
from  fractures,  treatment,  423 
gummatous,  in  tertiary  syphilis,  251 
heat  in,  87,  90-93 

impairment  of  special  functions  in,  77 
irritants  in,  94 
latent,  74 
massage  in,  90 
moist  gangrene  from,  157 
new  growths  of,  71 
of  antrum  of  Highmore,  714 
of  arteries,  308 

of  bone,  389.     See  also  Osteitis. 
of  bone-marrow,  398 
of  brain,  traumatic,  672 
of  bursa,  276 
of  nerve,  641 
of  non-vascular  tissue,  69 
of  peritoneum,  795 
of  thyroid  gland,  920 
of  urethra,  999 
of  vein,  304 
phlebotomy  in,  96 
plastic,  65 
resolution  of,  71 
retardation  of  circulation  in,  62 
serous,  64 
swelling  in,  76 
syphilitic,  of  vertebras,  251 
terminations  of,  71 
treatment,  constitutional,  95 

local,  79 

when  suppuration  is  threatened,  93 
tumefaction  in,  76 
vascular  changes  in,  60 
venesection  in,  96 
ventilation  in,  104 
water-bath  in,  93 


Ingrown  toe-nail,  919 
Inguinal  colostomy,  850 

hernia,  872 
Injector,  594 
Innominate  artery,  368 

ligation  of,  369 
Inoculations,  preventive,  36 

protective,  36 
Insects,  bites  of,  227 

stings  of,  227 
Insomnia,  syphilitic,  253 
Instruments,  disinfection  of,  50 

Schimmelbusch's  apparatus  for,  50 
Interdental  splints,  433 
Internal  clot,  325 

pudic  artery,  387 
Interpolation,  939 
Interrupted  suture,  56,  212 
Intertrigo  in  hereditary  syphilis,  261 
Intestinal  approximation,  consideration 
of  methods  of,  848 
obstruction,  775 
acute,  776 

by  fecal  accumulation,  776 
by  foreign  bodies,  776 
by  tumors,  776 
chronic,  symptoms,  776 
diagnosis,  777-779 
prognosis,  779 
treatment,  779 
tuberculosis,  195 
Intestine,  768 
resection  of,  835 
rupture   of,  withou     external  wound, 

762 
stricture  of,  776 
suture  of,  820-823 
tumors  of,  malignant,  783 
Intoxication,  putrid,  174 

septic,  174 
Intracranial  hemorrhage,  662 
tumors,  680 
treatment,  683 
Intraparictal  fissure,  location  of,  653 
Intra-uterine  fractures,  407 
Intravenous  infusion  of  saline  fluid,  352 
Intubation  of  larynx,  722 
Intussusception,  775 
operation  for,  849 
Involucrum,  396 
lodids,  100 

alkaline,  loi 
Iodoform,  28 
absorption,  fever  of,  117 
emulsion,  29 
gauze,  57 
poisoning,  29 
Iritis  in  syphilis,  249 
Irreducible  hernia,  866 
Irrigation  of  wounds,  52 

apparatus  for,  163 
Ischiorectal  abscess,  128,  888 

Jaboulay's  method  of  gastro-enteros- 
tomy,  832 


INDEX. 


IIOI 


Jacksonian  epilepsy.  68i 
lacobs  ulcer,  148.  296 
Janet's  method  for  treatment  of  gonor- 
rhea, 1004 
Jaw,  lower,  dislocations  of,  553 
excision  of,  612 
lumpy,  19,  235.     See  also  Actinomy- 
cosis. 
upper,  excision  of,  610 
Jejunostomy,  834 
Jerk-finger,  634 
Johnston's  quick  method  for  preparmg 

catgut,  55 
Joint,  Brodie's,  537 
Charcot's,  537 
dropsy  of,  531 
hysterical,  537 
strumous,  514 
Joints,  affections  of,  in  syphilis,  248 
aspiration  of,  594 
diseases  of,  510 
excisions  of,  595 
loose  bodies  in,  546 
neuralgia  of,  539 
tuberculosis  of,  196,  516 
Jones's  nasal  splint,  428 
Jordan's   (Forneaux)   method   for   hip- 
joint  amputation,  1055 
Jury-mast,  Sayre's,  702 
Justus's  test  for  syphilis,  253 

Kader'S  method  for  gastrostomy,  829 

Kangaroo-tendon,  55 

Karyokinesis,  112 

Keen's   modification   of    Cathcart  s   si- 

phonage  apparatus,  984 
Keith's  operation,  991 
Kelly's  catheter,  944 

catheterization  of  ureters,  944 
specula,  876 
Keloid,  272,  273 
Kidney,  abscess  of,  9S4 

diseases  and  injuries  of,  948 
dislocation  of,  949 
floating,  948 
injuries  of,  950 
laceration  of.  950 
movable,  948 
operations  on,  959 
rupture  of,  950 
surgical,  957 
tuberculosis  of,  197 

chronic,  958 
tumors  of,  948 
wandering.  948 
wounds  of,  perforating,  951 
Kidney-substance,  bleeding  from,  943 
"  Kite-shaped"  director,  589 
Knee,  housemaids',  626 

knock-,  635 
Knee-joint  disease,  524 
dislocations  of,  578 
erasion  of,  596 
excision  of,  605 
Sayre's,  double  extension  of,  526 


Knee-joint,  subluxation  of,  580 
Knife  for  amputation,  1037 
Knock-knee,  635 

osteotomy  for,  585 
Koch's  circuit,  32 
tuberculin.  199 
Kochers  incision  for  nephrotomy,  960 
method   for   anterior   gastro-enteros- 
tomy,  831 
for  excision  of  tongue,  750 
for  pylorectomy,  826 
of  circular  enterorrhaphy,  839 
of  lumbar  nephrectomy,  962 
of  reduction  of  shoulder-joint  dis- 
location, 561  _. 
operation  for  inguinal  hernia,  864 
Konig's   incision   for   lumbar  nephrec- 
tomy, 961 
Kraske's  operation,  887 
Krause's  method  of  skin-grafting,  941 
Kronig's  method  of  preparing  catgut,  54 
Kyphosis,  698 

Labial  hernia,  872 

Laborde's  method  of  artificial  respira- 
tion, 902 
Lacerated  wounds.  215 
Lachrymal  bone,  fractures  of,  428 
Lagoria's  sign,  477 
Laminectomy,  712 

La    Mothe's  method   for  reduction  of 
shoulder-joint  dislocation,  563 
Lancereaux's    treatment   of   aneun'sm, 

316 
Langenbeck's  operation,  604 
Lannelongue's  method  for  treatment  of 
hernia,  861 
of  exposing  liver,  803 
operation  for  microcephalus.  656 
Laparotomy,  813 

Laplace's  forceps  for  intestinal  anasto- 
mosis, 842 
Larrey's  operation,  1043 
Laryngeal  cartilages,  fractures  of,  434 
Laryngotomy,  quick,  722 
Laryngotracheotomy,  722 
Larynx,  abscess  of,  128 
blood-supply  of,  720 
diseases  and  injuries  of,  715 
edema  of,  715 
intubation  of,  722 
operations  on,  719 
wounds  of,  716 
Latent  inflammation,  74 
Lateral  sinus,  location  of,  654 
Lautenschlager's    steam    sterilizer    for 

dressings,  57 
Lawn-tennis  arm.  618 
Le  Dentu's  tendon-suture.  631 
Leech,  artificial,  83 
Leeching,  81 
Lee-Metford  bullet,  219 
Le  Fort's  tendon-suture,  631 
Leg.  amputations  of,  1048 
fractures  of,  502 


1 102 


INDEX. 


Leg,  ulcers  of,  141 

varix  of,  307  ■ 

operation  for,  349 
Legs,  bow-,  635 
Leiomyomata,  278 
Lejar's  tendon-suture,  631 
Lembert's  suture,  821 
Leontiasis  ossium,  403 
Leptomeningitis,  acute,  673 
Leptothrix,  21 
Leucomains,  34 

Leukocyte,  ameboid  movements  of,  66 
Leulcocytosis,  67 

Levis's  splints  for  fracture  of  lower  end 
of  radius,  470 
for    reduction    of    dislocation     of 
phalanges,  570 
Ligation  in  inferior  carotid  triangle,  372 

in  superior  carotid  triangle,  373 

in  triangle  of  election,  373 

in  triangle  of  necessity,  372 

of  abdominal  aorta,  387 

of  anterior  tibial  artery,  378,  379 

of  arteries  for  aneurysm,  318 
in  continuity,  356 

of  axillary  artery,  365  , 

of  brachial  artery,  363 

of  carotid  artery,  common,  372-374 

of  dorsalis  pedis  artery,  577 

of  external  iliac  by  Abernethy's   ex- 
traperitoneal method,  385 

of  facial  artery,  375 

of  femoral  artery,  383 

of  gluteal  artery,  386 

of  iliac  arteries,  384 

of  inferior  thyroid  artery,  368 

of  innominate  artery,  369 

of  internal  pudic  artery,  387 

of  lingual  artery,  375 

of  occipital  artery,  376 

of  popliteal  artery,  380-382 

of  posterior  tibial  artery,  380 

of  radial  artery,  360,  361 

of  sciatic  artery,  387 

of  subclavian  artery  in  third  part,  366 

of  superior  thyroid  artery,  374 

of  temporal  artery,  376 

of  ulnar  artery,  362 

of  vertebral  artery,  368 
Ligature,    application    of,    for    hemor- 
rhoids, 882 

diagram  showing  action  of,  358 

lateral,  to  vein,  338 

subcutaneous,  for  varicocele,  350 
Ligature-material,  52     ' 
Lightning,  effects  produced  by,  1078 
Lilienthal's  probe,  224 
Limb,  moist  gangrene  of,  157 
Line  of  demarcation,  153 
Linear  craniotomy,  692 
Lingual  artery,  375 
Lip,  lower,  carcinoma  of,  746 
cheiloplasty  of,  747 
removal  of,  747 
Lipoma,  diffuse,  270 


Lipoma,  nevoid,  283 

telangiectodes,  270 
Lipomata,  269 

treatment,  271 
Lisfranc's  amputation  of  shoulder-joint, 
1044 

operation   for   amputation    at    tarso- 
metatarsal articulation,  1045 
Lister's  cyanid  gauze,  58 

method  for  excision  of  wrist-joint,  601 
Litholapaxy,  985 

after-treatment,  990 

in  male  children,  990 
Lithotomy,  981 

lateral,  981 

suprapubic,  983 
Lithotrite,  Bigelow's,  987 

Forbes's,  987 

Thompson's,  987 
Lithotrity,  perineal,  991 

rapid,  985 
Liver,  802 

abscess  of,  127,  804 

hydatid  cysts  of,  803 

movable,  805 

rupture  of,  764,  802 

tuberculosis  of,  195 

wounds  of,  802 
Lloyd's  (Jordan)  symptom  of  renal  cal- 
culus, 953 
Lockjaw,  184.     See  also  Tetanus. 
Lordosis,  698 
Lorenz's  operation,  613 
Loreta's  operation,  823 
Ludwig's  angina,  166 
Lumbago,  614 
Lumbar  abscess,  137,  140 

hernia,  874 

puncture,  713 
Lumpy  jaw,  19,  235.     See  also  Actino- 
mycosis. 
Lung,  abscess  of,  128,  733 

contusion  of,  730 

diseases  and  injuries  of,  723 

gangrene  of,  733 

hernia  of,  731 

operations  on,  735 

rupture  of,  730 

tubercular  cavity  of,  733 
Lupus,  194 

exedens,  194 

hypertrophicus,  194 

vulgaris,  194 
Lustgarten's  bacillus,  43 
Luxatio  erecta,  559 

Luxations,  547.     See  also  Dislocations. 
Lymph,  565 
Lymphadenitis,  acute,  923 

cervical,  197 

chronic,  923 

infective,  923 
Lymphadenoma,  197,  924 
Lymphangiectasis,  284,  924 
Lymphangioma,  924 

circumscriptum,  924 


INDEX. 


HO- 


Lymphangiomata,  284 

cavernous,  284 

of  tongue,  284 
Lymphangitis,  923 
Lymphatic  abscess,  134 

glands,  abscess  of,  cold,  138 
tuberculosis  of,  196 

warts,  924 
Lymphatics,  diseases  and  injuries  of,  923 

varicose,  924 
Lymphoma,  malignant,  924 
Lymphorrhea,  924 
Lymphosarcoma,  286 
Lymph-scrotum,  284 
Lyssa,  232 

MacCormac'S   method    of    measuring 

for  truss,  860 
Macewen's  method  for  compression  of 
abdominal  aorta,  1053 
operation,  585 

for  congenital  hernia,  862 
for  inguinal  hernia,  861 
suprameatal  triangle,  location  of,  654 
Macroglossia,  284 
Maculse  of  syphilis,  246 
Maculopapular  syphilides,  245 
Madelung's  operation  for  varix  of  leg, 

349 
Madura-foot,  19 

Maisonneuve's  method  of  internal  ure- 
throtomy, 1013 
symptom,  468 
urethrotome,  1014 
Malar  bone,  fractures  of,  430 
Malaria,  117 

Malgaigne's  operation  for  harelip,  742 
Malignant  edema,  226 

bacillus  of,  44 
pustule,  230.     See  also  Anthrax. 
tumors,  268 
Malingering,  708 
Mallet,  raw-hide,  585 
Mallet-finger,  634 
Mammary  gland,  abscess  of,  cold,  138 

adenocele  of,  1060 

angioma  of,  1061 

cancer  of,  1062,  1063 

carcinoma  of,  1062 
treatment,  1065 

cystic  adenoma  of,  1060 

cysts  of,  1059-1062 

fibro-adenoma  of,  1060 

fibroma  of,  cystic,  1061 

myxoma  of,  106 1 

sarcoma  of,  1062 

scirrhus  of,  1063,  1064 

tuberculosis  of,  137 

tumors  of,  1059-1062 
Mammillitis,  1055 
Mannlicher  bullet,  218 
Marcy's  buried  tendon-suture,  56 
Marie's  disease,  537 
Marine  sponges,  preparation  of,  59 
Marjolin's  ulcer,  148 


Mason's  pin  in  fracture  of  nasal  bones, 

428 
Massage  in  inflammation,  890 

in  treatment  of  fractures,  419 
Mastitis,  acute,  1056 

chronic,  1058 

lobular,  1058 
Mastodynia,  1059 
Mastoid  cavity,  "  papering"  of,  692 

suppuration,  operations  for,  690 
Mathew's  speculum,  876 
Maunsell's  method  of  anastomosis,  838 
Mauser  bullet,  219 

Maxillary    antrum,    inflammation    and 
abscess  of,  714 

bone,  inferior,  fractures  of,  431 
superior,  fractures  of,  429 
Maydl's  operation,  850 
Mayer's  dressing  for  Thiersch's  method 

of  skin-grafting,  941 
McBurney's  point,  790 
McCormick's  operation,  644 
Mclntyre's  splint,  488 
Mediastinum,  abscess  of,  128 
Medulla,  tumors  of,  683 
Medullary  carcinoma,  297 
Melanosis,  298 
Melanotic  sarcoma,  286 
Meniere's  disease  in  syphilis,  248 
Meninges,  spinal,  puncture  of,  713 
Meningitis,  tubercular,  674 
Meningocele,  656,  693 
Meningomyelitis,  708 
Meningomyelocele,  693 
Mercier's  double-elbowed  catheter,  968 
Mercury,  100 
Metacarpal  bones,  dislocation  of,  569 

excision  of,  603 
Metacarpus,  fractures  of,  473 
Metastasis,  285 
Metatarsal  bones,  dislocations  of,  584 

fracture  of,  509 
Metatarsalgia,  639 
Microbes,  17,  18 

antagonistic,  38 

pus-,  39 

pyogenic,  39 

surgical,  41 
special,  39 
Microbic  gangrene,  151 
Microcephalus,  655 
Micrococci,  20 
Micrococcus,  divisions  of,  21 

pyogenes  tenuis,  40 

tetragenus,  41 
Micro-organisms,  17 
Microphyta,  18 
Microzoaria,  18 
Micturition,  frequency  of,  947 
Middle  lobe,  278 

Milzbrand,  230.     See  also  Anthrax. 
Miners'  elbow,  626 
Mirault's  operation  for  harelip,  743 
Moist  gangrene,  151,  156 
Mole,  272 


II04 


INDEX. 


Mole,  hydatid,  of  pregnancy,  278 

Mollities  ossium,  402 

MoUuscum  fibrosum,  272,  280 

Monococci,  20 

Monteggia's  dislocations,  577 

Moore's  dressing  in  fracture  of  clavicle, 

446 
Morbus  coxEe,  517.     See  also  Tubercu- 
losis of  hip-joint. 

coxarius,  516 
Morphea,  273 

Mortification,  150.     See  also  Gangrene. 
Morton's  disease,  639 
Mother's  marks,  282 
Moulds,  18 

Mouth,  diseases  of,  741 
Muco-pus,  121 

Mucous  membranes,  affections  of,  syph- 
ilitic, 247 
wounds  of,  236 

patches  in  syphilis,  247 
Miiller's  law,  264 
Mummification,  155 

Murray's  operation  for  ligation  of  ab- 
dominal aorta,  388 
Muscae  voUtantes  in  hemorrhage,  327 
Muscle,  repair  of,  113 
Muscles  and  ligaments,  spinal,  injuries 
of,  70s 

atrophy  of,  615 

contractions  of,  619 

contusions  of,  617 

degeneration  of  615 

diseases  and  injuries  of,  614 

dislocations  of,  619 

hernia  of,  619 

hypertrophy  of,  615 

inflammation  of,  caused  by  syphilis, 
616 

operations  on,  628 

rupture  of,  618 

strains  of,  617 

tumors  of,  616 

wounds  of,  617 
Myalgia,  614 
Mycosis  fungo'ides,  288 
Myomata,  278 

intramural,  278,  279 
Myositis,  infective,  615 

ossificans,  616 
Myxoma  of  mammary  gland,  1061 
Myxomata,  277,  278 
Myxosarcomata,  277 

Nails,  affections  of,  in  syphilis,  248 

diseases  of,  915 
Nares,  plugging  of,  for  epistaxis,  342 
Nasal  bones,  fractures  of,  426 
Jones's  splint  in,  428 
Mason's  pin  in,  428 
Nasopharyngeal  fibromata,  271 
Neck,  anatomy  of,  369 

triangles  of,  369 
Necrosis,  141 

acute,  391 


Necrosis,  causes  of,  396 

central,  396 

from  osteitis,  390 

from  osteomyelitis,  400 

of  bone,  395 

post-febrile,  397 

quiet,  396 

symptoms,  397 

treatment,  398 
Needles,  Hagedorn's,  331 
Nelaton's  dislocation,  582 
Neoplasms,  264 
Nephrectomy,  961 
Nephrolithotomy,  960 
Nephropexy,  963 
Nephroptosis,  948 
Nephrorrhaphy,  963 
Nephrotomy,  386,  959 
Nerve,  inflammation  of,  641 

repair  of,  113 

sciatic,  stretching  of,  646 
Nerve-suture,  645 
Nerves,  contusions  of,  644 

diseases  and  injuries  of,  641 

operations  upon,  645 

pressure  upon,  644 

section  of,  642 

ulnar,  dislocation  of,  at  elbow,  644 

wounds  and  injuries  of,  642 
punctured,  644 
Nervous  syphilis,  252 
Nervousness  of  bladder,  947 
Neuber's   plan    for   treating   knee-joint 

disease,  526 
Neuralgia,  641 

intercostal,  614 

of  joints,  539 

of  stumps,  642 
Neurasthenia,  traumatic,  706 
Neurectasy,  646 
Neurectomy,  646 

of  inferior  dental  nerve,  647 

of  infra-orbital  nerve,  647 

of  supra-orbital  nerve,  647 
Neuritis,  641 

due  to  fracture  of  shaft  of  humerus, 
treatment,  455 

in  syphilis,  253 
Neurofibroma,  280,  281 
Neuromata,  280 
Neuroparalytic  ulcer,  148 
Neurorrhaphy,  645 
Neurotomy,  646 
Nevi,  282 

Nevoid  lipoma,  283 
Nevolipoma,  270 
Nipple,  cysts  of,  1059 

Paget's  disease  of,  1059 

tumors  of,  1059 
Nitrous-oxid  gas  as  anesthetic,  907 
Nitze's  catheter,  944 
Node,  392 

Nodosities,  Heberden's,  535 
Noma,  163 

vulvae,  164 


IXDEX. 


1 105 


Non-vascular  tissue,  inflammation  of,  69 

wounds  in,  healing  of,  112 
Nose,  diseases  and  injuries  of,  713 

foreign  bodies  in,  713 

hemorrhage  from,  342 
Nosophen,  30 
Nucleins,  31 
Nucleus,  dividing,  forms   assumed   bv. 


Obligate  aerobic  bacteria,  23 
Obstructed  hernia,  866 
Obstrucdon,  intestinal,  775 
Obturator  hernia,  874 
Occipital  arter\",  376 

lobe,  tumors  of,  682 

triangle,  371 
Odontomata,  276 
Odontomes,  composite,  277 

epithelial,  276 

fibrous,  276 

follicular,  276 

radicular,  277 
0'D\vyer-Fell  apparatus,  729 
O'Dwyer's  operation.  722 
Ogston's  operation,  586 
Oidium  albicans,  18 
Onychia,  919 

in  syphilis,  248 
Operation,  Adam's,  587 

Agnew's,  for  webbed  fingers,  634 

Allingham's,  for  hemorrhoids,  881 

Bassini's,  for  femoral  hernia,  865 
for  inguinal  hernia,  863 

Bigelow's,  985 

Bodine's,  of  colostomy,  851 

Bottini's,   galvanocaustic,   for  h\-per- 
trophy  of  prostate  gland,  1028 

Brandt's,  of  stomach-reefing   for   di- 
lated stomach,  834 

Cheyne's,  for  femoral  hernia,  865 

Cock's,  1019 

Cooper's,  388 

Diday's,  for  webbed  fingers.  634 

Dupuytren's,  for  amputation  at  shoul- 
der-joint, 1044 

Buret's,  834 

during  shock.  208 

Estlander's,  738 

Fabricius's,  for  femoral  hernia,  865 

Fergusson's.  for  cleft  palate,  745 
for  varix  of  leg,  349 

for  appendicitis,  816-^20 

for  fistula  in  ano,  890 

for  intussusception,  849 

for  ligation  of  arteries  in  continuity, 
356 

for  pericardial  effusion,  348 

for  pericardial  suppuration,  348 

for  stone  in  women,  991 

for  varicocele,  350 

for  varix  of  leg,  349 

Fowler's,  for  inguinal  hernia,  864 

Gant's,  587,  588 

Grant's,  for  carcinoma  of  lip,  746 

70 


Operation,     Gritti's,      for     amputation 
through  the  femoral  condyles, 
105 1 
Gross's,  605 

Halsted's,  for  cancer  of  breast,  1065- 
1067 

for  inguinal  hernia,  863 

for  lateral  anastomosis,  845,  846 
Hancock's,  for  excision  of  knee-joint, 
I  607 

I      Heineke-Mikulicz,  824 
;      Hey's,  for  amputation  at  tarsometa- 
tarsal aruculation,  1046 
Hofifa's,  613 
Keith's,  991 

Kocher's,  for  inguinal  hernia,  864 
Kraske's,  887 
Langenbecks,  604 
Larrey's,  1043 

Lisfranc's,  for  amputation   at   tarso- 
metatarsal articulation,  1045 
Lorenz's,  613 
Loreta's,  823 
Macewen's,  585 

for  congenital  hernia,  862 

for  inguinal  hernia,  861 
Madelung's,  for  varix  of  leg,  349 
Malgaigne's,  for  harelip,  742 
Maydl's,  850 
McCormick's,  644 
Mirault's,  for  harelip,  743 
Murray's,  for  ligation  of  abdominal 

aorta,  388 
0'D\wer's,  722 
Ogston's,  586 
on  abdomen,  813 
on  bladder.  981 
on  bones,  585 
on  brain.  686 
on  kidney,  959 
on  nerves.  645 
on  skull,  686 
on  spine,  712 
on  ureter,  959 
on  vascular  system,  348 
Parker's,  604 

Phelps's,  for  varix  of  leg,  350 
preparation  of  patient  for.  51,  893 
preparations  for,  47 
prevention  of  shock  in,  207 
Rouge's,  278 
Sabanejeff 's,  for  amputation  through 

femoral  condyles,  1052 
Schede's,  739 

for  varix  of  leg,  349 
Sedillot's,  for  leg-amputation,  1049 
Senn's,  for  fecal  fistula.  850 

for  fixing  kidney.  963 

for  gastrostomy,  830 
Ssabanejew-Frank,  829 
sterilization    of  hands   and   forearms 

for.  48 
Syme's,  1018 

Trendelenburg's,  for  varix  of  leg,  349 
Treves's  593 


iio6 


INDEX. 


Operation,  use  of  gloves  in,  49 
Van  Hook's,  964 
Volkmann's,  1033 
Wheelhouse's,  1019 
Whitehead's,  for  excision  of  tongue, 

751 
for  hemorrhoids,  881 
Ophthalmia,  gonorrheal,  treatment,  1009 
Ophthalmoplegia  in  syphilis,  251 
Opisthotonos  in  tetanus,  185 
Orchidectomy,  1032 

bilateral,  1029 

unilateral,  1029 
Orchitis,  1031 
Orrhotherapy,  37 
Orthopedic  surgery,  632 
Orthotonos  in  tetanus,  185 
Os  calcis,  excision  of,  607 
Ossification,  local,  616 
Osteitis,  389 

necrosis  due  to,  390 

suppurative,  390 

treatment,  391 

tubercular,  196,  394 
Osteo-arthritis,  534 

of  hip-joint,  536 

treatment,  536 
Osteo-arthropathie  hypertrophiante 

pneumique,  537 
Osteocopic  pains  in  syphilis,  249 
Osteomalacia,  402 
Osteomata,  275 
Osteomyelitis,  acute,  398 
of  vertebrae,  695 
treatment,  401 

chronic,  402 
Osteoperiostitis,  389 

diffuse,  treatment,  392 

in  syphilis,  249 

treatment,  391 
Osteophytes  in  hereditary  syphilis,  262 
Osteoplastic  resection  of  skull,  688 
Osteosarcoma,  287 
Osteotome,  585 
Osteotomy,  585 

cuneiform,  585 

for  bent  tibia,  587 

for  faulty  ankylosis  of  hip-joint,  587 

for  faulty  ankylosis  of  knee-jcint,  588 

for  genu  valgum,  585 

for  hallux  valgus,  589 

for  knock-knee,  585 

for  talipes  equinovarus,  589 

for  talipes  equinus,  590 

for  vicious  union  of  fracture,  589 

linear,  585 

longitudinal,  for  osteitis,  392 

of  femur,  shaft  of,  below  trochanter, 
587-  588 
Oval  amputation,  1039 

Pachymeningitis,  672 
Paget's  disease,  295,  534 

of  nipple,  1059 
Pain,  sympathetic,  73 


Palate,  soft,  suture  of,  744 
Palmar  abscess,  129,  621 
pad  in  hemorrhage  from  palmar  arch, 

337 

psoriasis  in  syphilis,  246 
Palsy,  syphilitic,  252 
Pancreas,  810 

cysts  of,  811 

hemorrhage  into,  810 
Pancreatitis,  acute,  811 
"  Papering"  of  mastoid  cavity,  692 
Papillomata,  291.     See  also  Warts. 
Papular  syphilides,  246 
Papulosquamous  eruption,  246 
Paquelin  cautery  in  hemorrhage,  336 
Paracentesis  auriculi,  348 

pericardii,  348 

thoracis,  735 
Paralysis,  postanesthetic,  905 

pseudohypertrophic,  615 
Paraphimosis  from  gonorrhea,  1002 

treatment,  1008 
Parasites,  19 
Paratrimma,  165 

Parieto-occipital  lobe,  tumors  of,  682 
Parker's  operation,  604 
Parkhill's  clamp  for  ununited  fractures, 

426 
Paronychia,  624 

in  syphilis,  245 
Pasteur  treatment  of  hydrophobia,  233 
Patella,  dislocations  of,  579 

fractures  of,  492 
Patient,  preparation   of,  for  operation, 

SI.  893 
Pearl  tumor,  273 
Pelvic  dislocations,  571 
Pelvis,  fractures  of,  440 
Penis,  amputation  of,  1023 

cancer  of,  1023 

diseases  and  injuries  of,  994 

fracture  of,  1022 

gangrene  of,  1023 

injuries  of,  994 
Perforating  ulcer,  149 
Periarteritis,  309 
Pericardial  effusion,  302 
operation  for,  348 

sac,  tapping  of,  348 

suppuration,  operation  for,  348 
Pericardium,  tuberculosis  of,  296 
Perineal  bruises,  995 

hernia,  974 

section,  1018 
Perinephric  abscess,  128,  956 
Perinephritis,  955 
Periostitis,  389-392 

in  syphilis,  248 
Peritoneal  tuberculosis,  195 
Peritoneum,  795 

injuries  with  damage  to,  760 

rupture  of,  760 
Peritonitis,  acute,  995 

bacteria  as  cause  of,  796 

circumscribed  suppurative,  796 


INDEX. 


1 107 


Peritonitis,  diffuse  septic,  797 
suppurative,  797 

gonorrheal,  looi 

perforative,  treatment,  798 

tubercular,  799 
Perivascular  tissue,  changes  in,  in  inflam- 
mation, 67 
Pernio,  915 

Peroxid  of  hydrogen,  28 
Pes  cavus,  638 

planus,  637 
Petechia,  203 

Petit's  spiral  tourniquet,  1037 
Phagedena,  164,  1021 

differentiation  of,  from  chancre,  242 

sloughing,  159 
Phagedenic  ulcer,  142,  148,  242 
Phagocytes,  35 
Phagocytosis,  35 
Phalanges,  dislocations  of  570,  584 

excision  of,  603 

fractures  of,  473 
Pharynx,  foreign  bodies  in,  717 
Phelps's  operation  for  varix  of  leg,  350 
Phimosis,  1022 

from  gonorrhea,  1002 
treatment,  1008 
Phlebectasia,  305 
Phlebitis,  304,  305 
Phlebotomy,  351 

in  inflammation,  96 
Phlegmonous  erysipelas,  182 

suppuration,  122 
Phthisis,  syphilitic,  252 
Pick's  table  of  dislocations  of  shoulder- 
joint,  560 
Piles,  306,  878.     See  also  Hemorrhoids. 
Pirogoff's   method   for   amputation    at 

ankle-joint,  1048 
Plantar  psoriasis  in  syphilis,  246 
Plaster-of- Paris  bandage,  937 

jacket,  702 
Plastic  inflammation,  65 

surgery,  938 
Pleura,  diseases  and  injuries  of  723 

operations  on,  735 

tuberculosis  of  196 
Pleural    sac,   exploratory  puncture    of 

735 
Pleuritic  effusion,  723 

relief  of,  94 
Pleuritis,  traumatic,  730 
Pleurodynia,  614 
Pleurosthotonos  in  tetanus,  185 
Pneumonia,  bacillus  of,  43 
Pneumothorax,  non-traumatic,  726 

traumatic,  acute,  728 
Pneumotomy,  733 

for  abscess  of  lung,  740 
Pointing  of  abscess,  124 
Points  douloureux,  75 
Poisoned  wounds,  225 
Polydactylism,  634 
Polypi,  fleshy,  279 

gelatinous,  277 


Polypi,  mucous,  278 

nasal,  278 
Pons,  tumors  of,  682 
Popliteal  artery,  380 

ligation  of  380 
Port-wine  stains,  282 
Positive  chemiotaxis,  67 
Postanesthetic  paralysis,  905 
Posterior  tibial  artery,  379 
ligation  of,  380 

triangle  of  neck,  370 
Post-febrile  gangrene,  166 
Postoperation  rise  of  temperature,  115 
Postpharyngeal  abscess,  136,  140 
Pott's  aneurysm,  311,  323 

disease,  699 

fracture,  505 

gangrene,  153 
Poultice,  92 

Precentral  sulcus,  location  of  653 
Pregnancy,  hydatid  moles  of,  278 
Preparations  for  operation,  47 
Preventive  trephining,  666 
Primary  syphilis,  239 

union,  105 
Probe,  Lilienthal's,  224 

telephonic,  Girdner's,  223 
Probing,  223 
Proctoscopy,  875 
Prolapse  of  anus,  882  ' 

of  rectum,  882 
Properitoneal  hernia,  874 
Prostate,  abscess  of  129 

from  gonorrhea,  treatment,  1008 

diseases  and  injuries  of  994 

gland,  hypertrophy  of  1025 

hemorrhage  from,  946 

tuberculosis  of,  latent,  1031 
Prostatectomy  for  hypertrophy  of  pros- 
tate gland,  1028 
Prostatitis,  acute,  from  gonorrhea,  treat- 
ment, 1008 

chronic,  1003 

in  gonorrhea,  treatment,  1008 
Prostatorrhea,  1024 
Proud  flesh,  iii,  145 
Pruritus  of  anus,  891 
Psammoma,  273 
Pseudarthrosis,  417 
Pseudohypertrophic  paralysis,  615 
Pseudoleukemia,  924 
Psoas  abscess,  136,  138 
Psoriasis,  palmar,  in  syphilis,  246 

plantar,  in  syphilis,  246 
Psorosperm  of  Darier,  268 
Psorospermosis,  268 
Ptomains,  33 
Ptosis  in  syphilis,  252 
Ptyalism,  acute,  from   mercurial  treat- 
ment of  syphilis,  257 
Pudendal  hernia,  874 
Pulmonary  artery,  embolus  in,  171 

congestion,  acute,  302 

tuberculosis,  195 
Pulpy  degeneration,  196,  514 


iio8 


INDEX. 


Puncture,  blood-letting  by,  8i 

lumbar,  713 

of  spinal  meninges,  713 
Punctured  wounds,  216 
Purulent  effusions,  134 

infiltration,  122 
Pus,  119 

blue,  121 

caseous,  121 

concrete,  121 

curdy,  121 

fibrinous,  121 

forms  of,  120 

gummy,  121 

healthy,  120 

ichorous,  121 

laudable,  120 

malignant,  121 

microbes,  39 

muco-,  121 

orange,  121 

sanious,  121 

scrofulous,  121 

serous,  121 

stinking,  121 

tubercular,  121 

watery,  121 
Pustular  syphilides,  246 
Pustulation,  95 
Pustule,  malignant,  230 
Putrid  intoxication,  174 
Pyelitis,  955 
Pyelonephritis,  955 
Pyemia,  177 

arterial,  178 

streptococcus  of,  41 

treatment,  179 
Pylorectomy,  824-827 

Kocher's  method,  826 
Pyloric  orifice,  constriction  of,  773 
Pyloroplasty,  824 

Pylorus,  digital  dilatation  of,  for  cica- 
tricial stenosis,  823 

excision  of,  824-827 
Pyogenic  microbes,  39 
Pyonephrosis,  957 

Quilled  suture,  213,  215 
Quincke's  lumbar  puncture,  713 

Rabies,  232 

Racket  amputation,  1039 
Radial  artery,  359 
ligation  of,  360 

incision,  601 
Radius,  dislocations  of,  566 

fractures  of,  465 

subluxation  of  head  of,  567 
Railway  spine,  706,  707 
Ranula,  748 
Rawhide  mallet,  585 
Raynaud's  gangrene,  152,  159 
Rectum,  cancer  of,  884 

cleansing  of,  52 

diseases  and  injuries  of  875 


Rectum,  examination  of,  875 

foreign  bodies  in,  888 

gonorrhea  of,  loio 

hemorrhage  from,  343 

prolapse  of,  882 

stricture  of,  non-cancerous,  884 

ulcer  of,  883 

wounds  of,  888 
Recurrent  bandage  of  head,  936 

of  stump,  937 
Red  infarction,  170 
Reef-knot,  358 

square,  method  of  tying,  330 
Renal  calculus,  952 

complications  after  anesthetics,  904 

hematuria,  944 
Renipuncture,  963 
Repair,  105 

Reptiles,  bites  and  stings  of,  227 
Resection  of  rib,  736 

of-  skull,  osteoplastic,  688 
Residual  abscess,  196 

urine,  1025 
Resolution  of  inflammation,  71 
Respiration,  artificial,  902 
Respiratory  disorders  after  anesthetics, 
904 

organs,  surgery  of,  713 
Retardation  of  circulation,  62 
Retention  of  urine,  965 

from  enlarged  prostate,  treatment, 

968 
in  gonorrhea,  treatment,  1008 
Retention-cysts,  299 
Retinitis,  diffuse,  in  syphilis,  249 
Retrenchment,  939 
Retroclusion,  332 
Retropharyngeal  abscess,  136 
Reverdin's    method    of      skin-grafting, 

939 
Rhabdomyomata,  278,  287 
Rhachitis,  200,  201 
Rheumatic  torticollis,  614 
Rheumatism,  gonorrheal,  530 

muscular,  614 
Rhigolene  as  freezing  agent,  908 
Rhinoplasty,  942 

Indian  method,  941,  942 

Italian  method,  941.  942 

Tagliacotian  method,  942 
Rhoads's  apparatus  for  dislocation  of 

acromial  end  of  clavicle,  557 
Ribbail's  bandage,  930 
Ribs,  dislocation  of,  571 

excision  of,  609 

fractures  of,  435 

resection  of,  736 
Rickets,  200,  201 
Rider's  bone,  616 

leg,  618 
Risus  sardonicus  in  tetanus,  185 
Robson's  decalcified  bone  bobbin,  839 

method   of    circular    enterrorrhaphy, 

839 
Rodent  ulcer,  148,  296 


INDEX. 


1  109 


Rokintansky's  diveiticiilar  lu'rni;L',  874 
Rolando's    fissure,    location      of,    651, 

653 
Rontgen  rays,  1068.     Sue  also  X-rays. 
in  diagnosing  fracture,  413,  415 
in  fractures  and  dislocations,  1077 
Rosenthal's  test  for  blood  in  urine,  943 
Roseola  of  syphilis,  245 
Rouge's  operation,  278 
Round  bullet,  217 
Rubber  dams,  58 
Rupia,  246 

in  tertiary  syphilis,  250 
Rupture,  857.     See  also  Hernia. 

muscular,  from  contusion  of  abdomi- 
nal wall,  760 

of  bile-ducts,  765 

of  bladder,  970 

of  diaphragm,  730 

of  gall-bladder,  765 

of  intestine  without  external  wound, 
762 

of  kidney,  950 

of  liver,  764,  802 

of  lung, 730 

of  muscle,  618 

of  peritoneum,  760 

of  sinus,  664 

of. spleen,  765,  812 

of  stomach  without  external  woimd, 
761 

of  tendons,  620 

of  urethra,  995 

Sabanejeff's  operation  for  amputation 
through  femoral  condyles,  1052 
Saccharomyces,  18 
Sacro-iliac  disease,  516 
Sacrum,  fractures  of,  442 
Saddle-back,  6g8 
Salivation  from  mercurial  treatment  of 

syphilis,  257 
Sapremia,  174 

from  acute  osteomyelitis,  400 
Saprophytes,  19 
Sarcina,  20 

Sarcocele,  syphilitic,  249 
Sarcoma,  285 

alveolar,  287 

black,  287 

erysipelas  as  a  cure  for,  290 

giant-celled,  287 

hemorrhagic,  288 

melanotic,  286,  287 

myeloid,  287 

of  mammary  gland,  1062 

plexiform,  288 

round-celled,  286 

spindle-celled,  286 

telangiectatic,  288 

treatment,  289 

varieties,  286 
Sardonic  smile  in  tetanus,  185 
Saviard's  aneurysm-needle,  356 
Saws  for  amputation,  1037 


Sayre's    adhesive-plaster    dressing    for 
fracture  of  clavicle,  446 

double  extension  of  knee-joint,  526 

jury-mast,  702 

knee-splint,  525 

long  splint,  523 

plaster-of- Paris  jacket  702 
Scalds,  911 

of  glottis,  914 
Scalp,  abscess  of,  655 

diseases  of,  654 
Scalp-wounds,  658 
Scapula,  dislocations  of  lower  angle  of, 

557 
excision  of,  609 
fractures  of,  448 
Scarification,  81 
Scarificator,  83 
Scarlet  fever,  surgical,  118 
Scarpa's  triangle,  382 
Schede's  operation,  739 
for  varix  of  leg,  349 
Schimmelbusch's   apparatus  for  steriliz- 
ing instruments,  50 
Schizomycetes,  18,  19 
Schleich's  new  anesthetic  agent,  906 
Sciatic  artery,  387 

hernia,  874 
Scirrhous  carcinoma,  297 
Scirrhus  of  mammary  gland,  1063,  1064 
Sclerosis,  arterial,  309 
Scoliosis,  696-698 
Scorbutic  ulcer,  149 
Scotch  douche,  90 
Scrofula,  193 
Scrofulodermata,  194 
Scrofulous  abscess,  134 
Scrotal  hernia,  872 
Scrotum,  lymph-,  284 
Scurvy,  201 
Sebaceous  cysts,  300 
Secondary  suturing,  112 

syphilis,  244 
Sedative  poultice,  92 
Sedillot's  leg-arnputation,  1049 
Selva's  thumb  bandage,  929 
Seminal  vesicles,  diseases  and  injuries 
of,  994 
vesiculitis,  1023 
Senile  gangrene,  151 
Senn's  apparatus  for  intracapsular  fract- 
ure of  femur,  481 
bone  ferrules,  590 

bone-chip  method  of  treating  necro- 
sis, 398 
bone-plate  in  lateral  intestinal  anasto- 
mosis, 843 
decalcified  bone-chips,  59 
entero-anastomosis,  843 
incision  for  amputation  of  breast,  1068 
method    for   anterior    gastro-enteros- 
tomy,  831 
for  excision  of  shoulder-joint,  600 
for  preparing  catgut,  54 
of  intestinal  anastomosis,  836 


II  lO 


INDEX. 


Senn's  operation  for  fecal  fistula,  850 
for  fixing  kidney,  963 
for  gastrostomy,  830 

silver  tube,  993 
Sepsis,  173 
Septic  infection,  176 

intoxication,  174 

wounds,  226 
Septicemia,  173 

streptococcus  of,  41 

true,  176 
Sequestrotomy,  398 
Sequestrum,  396 

diagram  illustrating  formation  of,  396 
Serous  inflammation,  64 
Serpiginous  ulceration,  242,  247 

ulcers  in  tertiary  syphilis,  250 
Serum,  antitoxin,  for  tetanus,  189 
Serum-therapy,  37 
Shekelton's  aneurysm,  310 
Shirt-stud  abscess,  133 
Shock,  205-207 

apathetic,  206 

from  wounds,  205 

in  anesthesia,  900 

operation  during,  208 

pretention  of,  in  operations,  207 

sudden  death  from,  206 

torpid,  206 
Shot,  small  wounds  by,  222 
Shoulder-joint,  disarticulation  at,  1043 

disease,  526 

dislocations  of,  557 

excision  of,  597 

subluxation  of,  560 
Silicate-of-sodium  dressing,  938 
Silk  suture,  56 

Silk-web  catheter,  English,  970 
Silkworm-gut,  56 
Silver  as  an  antiseptic,  30 

lactate,  30 

wire  sutures,  preparation  of,  56 
"  Silver-fork  deformity,"  468 
Sinus,  149 

frontal,   distention    and    abscess    of, 

715 
trephining  of,  688 

lateral,  location  of,  654 

rupture  of,  664 

superior  longitudinal,  location  of,  654 

treatment,  150 
Sinus-thrombosis,  infective,  679 
Skiagraphs,  taking  of,  1074-1077 
Skiagraphy,  1068 
Skin,  diseases  of,  915 

repair  of,  114 

syphilitic  diseases  of,  244 
treatment,  258 

tuberculosis  of,  194 
Skin-grafting,  939-941 
Skull,  bones  of,  diseases  and  malforma- 
tions of,  655 

fractures  of,  664 

natiform,  in  hereditary  syphilis,  262 

operations  on,  686 


Skull,  resection  of,  osteoplastic,  688 
Sloughing,  163 

from  fracture,  treatment  of,  421 

phagedena,  159 
Smith's  anterior  splint,  486 

method    for    treating    shoulder-joint 
dislocation,  562 
Snake-bites,  228 
Snuff-box,  anatomical,  360 
Snuffles  in  hereditary  syphilis,  261 
Sorbefacients  in  inflammation,  88 
Spectroscopic  test  for  blood  in   urine, 

942 
Specula,  Kelly's,  876 

Mathew's,  876 
Spencer's  apparatus  for  infusion  of  saline 

fluid,  354 
Spermatic  cord,  diseases  and  injuries  of, 

994 
Spermatorrhea,  defecation-,  1024 
Sphacelus,  150 
Spica  of  groin,  933 
of  instep,  930 
of  shoulder,  933 
of  thumb,  929 
Spina  bifida,  693 

operations  for,  712 
Spinal  abscess,  treatment,  703 
caries,  699 

cord,  cocainization  of,  911 
concussion  of,  709 
contusion  of,  709 
wounds  of,  709 
curvatures,  695 
ligaments   and    muscles,    injuries    of, 

705 
meninges,  puncture  of,  713 
syphilis,  253 
Spine,  congenital  deformities  of,  693 
dislocations  of,  710 
fracture-dislocations  of,  710 
fractures  of,  710 
operations  on,  712 
railway,  706,  707 
surgery  of,  693 
tumors  of,  694 
Spiral  bandage  of  fingers,  928 
of  foot,  covering  heel,  930 
of  palm  or  dorsum  of  hand,  928 
reversed  bandage   of  lower  extremi- 
ties,'929 
of  upper  extremities,  927 
Spirilla,  20 
Spleen,  812 
abscess  of,  812 
rupture  of,  765,  812 
wandering,  812 
wounds  of,  812 
Splenectomy,  856 
Splenic  fever,  230 
Splenopexy,  813 

Splint,  anterior  angular,  for  fractures  in 
elbow-joint,  458,  459 
Stromeyer's,  528 
Bond's,  in  CoUes's  fracture,  471 


INDEX. 


nil 


Splint,   dorsal,    for    excision    of    ankle, 
Volkmann's,  607 
■Esmarch's,   for   treatment     after   ex- 
cision of  elbow-joint,  601 
interrupted,  603 
interdental,  433 

internal  angular,  in  fracture  of  surgi- 
cal neck  of  humerus,  452 
in  fracture  of  shaft  of  humerus, 

455 
knee,  Savre  s,  525 
knee-joint,  Hutchinson  s,  525 
Levis's,  for  fracture  of  lower  end  ol 
radius,  470 
for    reduction    of    dislocation     ot 
phalanges,  570 
long,  Sayre's,  523 
Mclntyre's,  488 
Smith's  anterior,  486 
straight,  for  fracture  of  both  bones  ot 

forearm,  465 
swing-,  Watson's  plaster-of-Pans,  606 
Thomas's,  posterior,  522 
Van  Arsdale's  triangular,  489,  49^ 
vulcanite,  433 
Splinter-fracture,  405 
Spondylitis,  699 

deformans,  536,  544,  705 
Sponges,  marine,  preparation  of,  59 
Spontaneous  evacuation  of  abscess,  124 
Sporadic  cretinism,  200 
Spores,  22 
Sporulation,  22 

Sprague  hot-air  apparatus,  513,  5^4 
Sprain-fracture,  405 
Sprains,  540 
fracture-,  541 
treatment,  542 
Sputum,  tubercle  bacilli  in,  43 
Ssabanejew-Frank  operation,  829 
St.  Anthony's  fire,  179 
Staphylococci,  20 
Staphylococcus  cereus  albus,  40 
ffavus,  40 
flavescens,  40 
pyogenes  albus,  40 
aureus,  39 
citreus,  40 
Staphylorrhaphy,  744 
Stay-knot,  manner  of  tying,  359 
Stenosis,  cancerous,  755 
cicatricial,  752 

of  orifices  of  stomach,  773 
spasmodic,  756 
Step-mother,  624 
Sterilization,  24? 

of  hands  and  forearms,  48 
Sterilized  gauze,  57 
Sterilizer,  portable,  51 

steam-,   for    dressings,    i^autenschla- 

ger's,  57 
Sternocleidomastoid  muscle,  division  ot, 

for  wry-neck,  628 

Sternum,  dislocations  of,  571 

fractures  of,  438 


Stimulants,  alcoholic,  102 
Stings  of  bees  and  insects,  227 
of  reptiles,  227 
of  wasps,  227 
Stitch,  Ford's,  822 
Stitches,  removal  of,  59 
Stomach,  768 

affections  of,  in  syphilis,  252 

carcinoma  of,  769 

cicatricial  stenosis  of  orifices  of,  773 

removal  of,  827 

rupture  of,  without  external  wound, 

761 
ulcer  of,  peptic,  771 
Stone  in  bladder,  972 

in  women,  operation  for,  991 
Strain  of  muscle,  617 

periostitis  due  to,  391 
Strain-fracture,  405 
Strangulated  hernia,  867 
Strangulation,  intestinal,  875 
Strapping  of  ulcer  of  leg,  145 
Strepto-bacilli,  21 
Streptococci  in  noma,  42 
Streptococcus  articulorum,  41 
of  erysipelas,  41 
of  pyemia,  41 
of  septicemia,  41 
pyogenes,  39,  4° 

malign  us,  40 
septicus,  40 
Stricture,  hysterical,  756 
of  esophagus,  752 
of  intestine,  776 
of  rectum,  non-cancerous,  884 
of  urethra,  1010-1012 
Stromeyer's  anterior  angular  sphnt,  528 
Strumous  joint,  514 
Struve's  test  for  blood  in  unne,  943 
Stumps,  neuralgia  of,  641 
Stupe,  91 

Subclavian  artery,  366 
ligation  of,  366 
triangle,  371 
Subdural  hemorrhage,  663 
Subluxation  of  head  of  radius,  567 
of  humerus,  619 
of  knee-joint,  580 
of  shoulder-joint,  560 
Submaxillary  triangle,  370 
Submental  triangle,  370 
Subphrenic  abscess,  127,  801 
Subungual  exostosis,  276 
Suffusion,  203 

Sulcus,  precentral,  location  ot,  553 
Superior  carotid  triangle,  370 
ligation  in,  373 
longitudinal  sinus,  location  of,  654 
thyroid  artery,  374 
Supernumerary  digits,  634 
Suppuration,  118,  121 
1      phlegmonous,  122 
Suppurative  felon,  129 
fever,  117.  126 
1      thecitis,  129 


III2 


INDEX. 


Suprameatal  triangle  of  Macewen,  lo- 
cation of,  654 
Surgeon's  knot,  method  of  tying,  330 
Surgical  cleanliness,  methods,  45,  46 

fevers,  115,  116 

kidney,  957 
Suture  a  distance,  646 

button,  214,  215 

continuous,  56,  212,  214 

Cushing's  right-angled,  821 

Czerny-Lembert,  822,  823 

Dupuytren's,  821 

Ford's,  ;2I3 

glovers'  stitch,  56 

Gussenbauer's,  823 

Halsted's,  56 

interrupted,  56,  212 

Lembert's,  821 

Marc)''s  buried  tendon,  56 

of  soft  palate,  744 

quilled,  213,  215 

subcuticular,  Halsted's,  213,  214 

twisted,  214,  215 

Wolfler's,  822,  823 
Suture-ligaments,  arrest  of  hemorrhage 
by, 331 

Suturing,  secondary,  112 

Sweet's  apparatus  for  locating  foreign 

bodies,  1073 
Swing-splint,  Watson's  plaster-of-Paris, 

606 
Sylvester's  method  of  artificial  respira- 
tion, 902 
Sylvius's  fissure,  location  of,  652 
Syme's  method  for  amputation  at  ankle- 
joint,  1047 
of  leg  through  femoral  condyles, 
1051 
operation,  1018 
staff,  1014 
Symmetrical  gangrene,  152,  159 
Syncope  in  anesthesia,  900 
Syncytioma  malignum,  298 
Syndactylism,  634 
Synovitis,  510 
chronic,  511 
pannous,  515 
simple  acute,  510 
Syphilides,  244 

diagnosis  between  secondary  and  ter- 
tiary, 247 
in  tertiary  syphilis,  250 
maculopapular,  245 
papular,  246 
pustular,  246 
tubercular,  247 
Syphilis,  237-264 
acquired,  238 

affections  of  bones  in,  248 
of  ear  in,  248 
of  eye  in,  249 
of  hair  in,  248 
of  joints  in,  248 
of  mucous  membranes  in,  247 
of  nails  in,  248 


Syphilis,  affections  of  stomach  in,  252 

of  testes  in,  249 
albuminuria  in,  252 
alopecia  in,  248 
amyloid  degenerations  in,  251 
arteritis  in,  250 
as  cause  of  inflammation  of  muscles, 

616 
ataxia  in,  251 
bacillus  of  43 
bald  patch  in,  247 
brain,  252 

calomel  fumigation  in,  255 
choroiditis  in,  249 
Colles's  law  in,  237,  261 
condylomata  in,  247 
diagnosis  between  secondary  and  ter- 
tiary lesions  of  247 
diffuse  retinitis  in,  249 
endarteritis  in,  252 
epididymitis  in,  249 
epilepsy  in,  252 
eruptions  in,  forms  of,  244 
fever  of,  243 
flat  condylomata  in,  246 
general,  243 
hereditary,  238,  260 

dactylitis  in,  262 

diagnosis,  262 

Hutchinson's  teeth  in,  263 

symptoms,  261 

treatment,  263 

Virchow's  sign  in,  262 
immunity  from,  237 
infection  in  utero,  261 
initial  lesions  of  240 
intermediate  period,  249 
Justus's  test  for,  253 
Meniere's  disease  in,  248 
mucous  patches  in,  247 
nervous,  252 
neuritis  in,  253 
of  skin,  244 

treatment,  258 
onychia  in,  248 
ophthalmoplegia  in,  251 
osteocopic  pains  in,  249 
osteoperiostitis  in,  249 
palmar  psoriasis  in,  246 
paronychia  in,  248 
periods  of  238 
periostitis  in,  248 
plantar  psoriasis  in,  246 
primary,  239 
ptosis  in,  252 

rules  of  inheritance  of,  260 
salivation   from    mercurial   treatment 

of,  257 
sarcocele  in,  249 
secondary,  244 
spinal,  253 
spondylitis,  251 
stages  of  238 
tertiary,  250,  251 
thrombosis  in,  250 


INDEX. 


III3 


Syphilis,  transmission  of,  238 
transmitted  congenital,  260 
treatment    of    complications    in   sec- 
ondary stage,  257 
in  primary  stage,  253 
in  secondary  stage,  254 
of  tertiary  stage,  259 
visceral,  252 
warts  in,  247 
Syphilitic   affections  of  mucous    mem- 
branes, 247 
arteritis,  309 
bubo, 242 
erythema,  245 
fever,  243 
insomnia,  253 
maculae,  245 
palsy,  252 
phthisis,  252 
roseola,  245 
sarcocele,  249 
skin-diseases,  244 
treatment,  258 
spots,  245 
ulcer,  143 
Syphilodermata,  244 
Svringomyelia,  281 
Syringomyelocele,  693 

Tabatiere  anatomique  of  Cloquet,36o 

Tabetic  arthropathy,  537 

Tache  cerebrale,  675 

Tagliacotian  method  of  rhinoplasty,  942 

Talipes,  636 

calcaneovalgus,  637 

calcaneovarus,  637 

calcaneus,  635,  636 

equinovalgus,  636 

equinovarus,  636 
osteotomy  for,  589 

equinus,  635,  636 
osteotomy  for,  590 

treatment,  637 

valgus,  636 

varus,  636 
-amputation,  1054 
Tarsal  bones,  dislocations  of,  584 
Tartar  emetic,  97 
T-bandage  of  perineum,  937 
Teale's  method  for  leg  amputation,  1049 
Technic  of  brain-operations,  689 
Telangiectasis,  282 
Temporal  artery,  376 
Temporosphenoidal  lobe,  tumors  of,  682 
Tenaculum,  330 
Tendon-lengthening,  630 
Tendons,  diseases  and  injuries  of,  614 

dislocations  of,  619 

operations  on,  628 

repair  of,  114 

ruptures  of,  620 

wounds  of,  620 
Tendon-sheaths  of  hand,  diagram  of,  621 
Tendon-suture,  630 

buried,  Marcy's,  56 


Tenosynovitis,  620.     See  also  Thecitis. 

Tenotomy,  628-630 

Tertiary  skin-eruptions  in  syphilis,  250 

stage  of  syphilis,  treatment,  259 

syphilis,  250 
Testes,  affections  of,  in  syphilis,  249 
Testicles,  diseases  and  injuries  of,  994 

encysted  hematocele  of,  1034 

encysted  hydrocele  of,  1034 

excision  of,  1032 

fungus  of,  197 

malplaced,  1030 

retained,  1030 

tuberculosis  of,  197,  1031 
Tetanus,  184 

antitoxin  serum  for,  189 

bacillus  of,  42 

of  newborn,  186 

treatment,  188 
Tetracocci,  20 
Theca,  1040 
Thecitis,  620 

suppurative,  129 
Thiersch's  method  of  skin-grafting,  940 

Mayer's  dressing  for,  941 
Thigh,  amputation  of,  1052 

fractures  of,  in  children,  488-490 
Thomas's  posterior  splint,  522 
Thompson's    diagnostic    questions     in 
urinary  diseases,  947 

divulsor,  1016 

evacuator,  988 

lithotrite,  987 

vesical  forceps,  992 
Thoracoplasty,  738 
Thoracotomy,  736-738 
Throat,  cut,  716 
Thrombo-arteritis,  169 
Thrombophlebitis,  169 

infective,  305 
Thrombosis,  167-169 

in  syphilis,  250 

sinus-,  infective,  679 
Thrombus,  ante-mortem,  168 

infected,  in  vein,  169 

white,  168 
Thumb,  amputation  of,  1041 

dislocation    of    metacarpophalangeal 
joint  of,  569 
Thyroid  gland,  atrophy  of,  919 
congestion  of,  920 
hypertrophy  of,  919 
inflammation  of,  920 
wounds  of,  919 
Thyrotomy,  719 
Tibia,  fractures  of,  502 
Tinnitus  aurium  in  hemorrhage,  327 

in  inflammation,  77 
Toe,  great,  excision  of  bones  of,  608 
Toes,  amputation  of,  1045 

fractures  of,  509 
Tongue,  carcinoma  of.  748 

complete  removal  of,  750 

diseases  of,  741 

lymphangiomata  of,  284 


1 1 14 


JXDEX. 


Tongue,  partial  removal  of,  749 

Tongue-tie,  748 

Tonics,  103 

Torpid  shock,  206 

Torsion  to  control  hemorrhage,  332 

Torsoclusion,  332 

Torticollis,  632 

division   of    sternocleidomastoid   for, 
628 

rheumatic,  614 

spasmodic,  632 
Tourniquet,  333 

application  of,  1036 

Charriere's,  1037 

Petit's  spiral,  1037 
Toxalbumins,  33 
Toxemia,  hydatid,  302,  803 
Toxins,  33 
Trachea,  diseases  and  injuries  of,  715 

foreign  bodies  in,  717 

operations  on,  719 
Tracheotomy,  719 

high,  720 
Transfixion,  332 
Transfusion,  arterial,  354 

of  blood,  352 
Transmission,  placental,  of  bacteria,  39 
Transthoracic  hepatotomy,  131 
Traumatic  fever,  115,  116 

gangrene,  spreading,  158 

hysteria,  707 

neurasthenia,  706 

neuromata,  281 
Trendelenburg  position,  B14 
Trendelenburg's  operation  for  varix  of 

leg.  349 
Trephine,  crown,  687 

Golt's  conical,  687 
Trephining  frontal  sinus,  688 

in  fracture  of  skull,  686 

preventive,  666 
Treves's  operation,  593 
Triangle  of  election,  ligation  in,  373 

of  necessit)',  370 
ligation  in,  372 

of  neck,  369-371  ' 

Scarpa's,  382 

suprameatal,    of   Macewen,    location 
of,  654 
Trichiniasis,  616 
Trichinosis,  616 
Trigger-finger,  634 
Tripper,  looi.     See  also  Gotiorrkea. 
Trismus  nascentium,  186 

neonatorum,  186 
Trophic  ulcer,  148 

Truss,  MacCormac's  method  of   meas- 
uring for,  860 
Tubercle,  190 

anatomical,  194 

subcutaneous  painful,  272 
Tubercular  abscess,  134 

adenitis,  ig6 

caries,  394 

cavity  of  lung,  733 


Tubercular  gummata,  194 

meningitis,  674 

osteitis,  196 

syphilides,  247 
Tuberculin,  Koch's,  199 

Hunter's  derivative  of,  200 
Tuberculosis,  190 

bacillus  of,  43,  191 

diagnosis,  197 

infection  with,  192 

intestinal,  195 

of  alimentary  canal,  195 

of  bone, 196, 389 

of  brain,  196 

of  hip-joint,  516-524 
treatment,  521-524 

of  joints,  196,  516 

of  kidney,  197 
chronic,  958 

of  liver,  195 

of  lymphatic  glands,  196 

of  mammary  gland,  137 

of  pericardium,  196 

of  pleura,  196 

of  prostate,  latent,  1031 

of  sacro-iliac  joint,  516 

of  skin,  194 

of  subcutaneous  connective  tissue,  194 

of  testicle,  197,  1031 

peritoneal,  195 

prognosis,  198 

pulmonary,  195 

treatment,  198,  199 
Tuffnell's  treatment  of  aneurysm,  315 
Tumefaction  in  inflammation,  76 
Tumors,  264-302 

causes,  265,  266 

classes  of,  264 

classification,  269 

connective-tissue,  innocent,  269 

malignant,  285.     See  also  Sarcoma. 

cystic  multilocular,  276 

epithelial,  innocent,  291 
malignant,  293 

fibrofatty,  269 

fibroid,  recurrent,  288,  289 

fibrous,  272 

heterologous,  265 

in  corpus  striatum,  682 

innocent,  268 

intracranial,  680 
treatment,  683 

malignant,  268 

mixed,  288 

of  bladder,  980 

of  bone,  389 

of  cerebellum,  683 

of  intestine,  malignant,  783 

of  kidney,  948 

of  mammary  gland,  1059,  1060 
malignant,  1062 

of  medulla,  683 

of  muscles,  616 

of  nipple,  1059 

of  occipital  lobe,  682 


INDEX. 


II15 


Tumors  of  parieto-occipital  lobe,  682 

of  pons,  682 

of  prefrontal  region,  682 

of  spine,  694 

of  temporosphenoidal  lobe,  682 

pearl,  273 
Tunica  vaginalis,  diseases  and  injuries 

of,  994 
Twisted  suture,  214,  215 
Typhoid  fever,  bacillus  of,  44 

Ulcer,  140 

adherent,  incisions  for,  144 

callous,  148 

classification  of,  141 

Curling's,  782 

edematous,  148 

erethistic,  147 

exuberant,  146 

fungous,  146 

healthy,  146 

hemorrhagic,  148 

indolent,  147 

irritable,  146,  147 

Jacob's,  148,  296 

Marjolin's,  148 

neuroparalytic,  148 

of  bowel,  782 

of  leg,  acute,  141 
chronic,  143 
inflamed,  141 
strapping  of,  145 

of  rectum,  883 

of  stomach,  peptic,  771 

painful,  147 

perforating,  149 

phagedenic,  142,  148,  242 

rodent,  148,  296 

scorbutic,  149 

serpiginous,  in  tertiary  syphilis,  250 

syphilitic,  143 

trophic,  148 

varicose,  147 
Ulceration,  140    . 

complications  in,  144 

herpetic,  differentiation  of,  from  chan- 
cre, 241 

serpiginous,  242,  247 
Ulna,  dislocations  of,  566 

fractures  of,  462 
Ulnar  artery,  361 
ligation  of,  362 

incision,  602 
Umbilical  hernia,  873.    See  also  Hernia. 
Union,  immediate,  106 

primary,  105 
Uranoplasty,  745 
Ureter,  catheterization  of,  944 

diseases  and  injuries  of,  948 

implantation  of,  intestinal,  964 

operations  on,  959 

wounds  of,  952 
Ureterolithotomy,  964 
Uretero-ureterostomy,  964 
Urethra,  diseases  and  injuries  of,  994 


Urethra,  foreign  bodies  in,  998 

inflammation  of,  999.     See  also  Ure- 
thritis. 

injuries  of,  994 
in  fracture,  442 

irrigation  of,  in  gonorrhea,  1004 

rupture  of,  995 

stricture  of,  loio 

wounds  of,  995 
Urethral  and  intravesical  irrigator,  Val- 
entine's, 1005 

catarrh,  chronic,  1003 

discharges,  chronic,  1003 
treatment,  1009 

fever,  1016 

hemorrhage,  946 

instruments,  male,  proper   curve   of, 
970 
Urethritis,  999 

eczematous,  1000 

gouty,  1000 

simple,  999 

specific,  looi.     See  also  Gonorrhea. 

traumatic,  1000 

tubercular,  1000 
Urethrorrhea  999 
Urethrotomes,  Gross's  exploratory,  1015 

Maisonneuve's,  1013,  1014 
Urethrotomy,    internal,    with    Maison- 
neuve's urethrotome,  1013 
Urinary  fever,  1017 
Urine,  residual,  1025 

retention  of,  965 

in  gonorrhea,  treatment,  1008 
Uterine  fibroid,  272,  278 

Vagina,  cleansing  of,  52 

Vaginal  hernia,  874 

Valentine's    urethral    and    intravesical 

irrigator,  1005 
Valleix's  points  douloureux,  75 
Van  Arsdale's  triangular  splint,  489,  491 
Van  Hook's  operation,  964 
Varicocele,  306,  1034 

operation  for,  350 

subcutaneous  ligature  for,  350 
Varicose  aneurysm,  323 

lymphatics,  924 

ulcer,  147 

veins,  305.     See  also  Varix 
Varix,  305 

aneurysmal,  311,  323 

of  leg,  307 

operations  for,  349 

treatment,  307 
Vascular  system,  operations  on,  348 
Vein,  application  of  lateral  ligature  to, 
338 

hemorrhage  from,  339 

inflammation  of,  304.     See  also  Phle- 
bitis. 

varicose,  305.     See  also  Varix. 

wounds  of,  326 
Velpeau's  bandage,  934 
Vense  comites,  357 


iii6 


INDEX. 


Venereal  catarrh,  looi.    See  also  Gonor- 
rhea. 
sore,  local,  1020 
warts,  291 
Venesection,  351 

in  inflammation,  96 
Venous  nevi,  282 
Ventral  hernia,  873 
Veratrum  viride,  97 
Vermiform  appendix,  abscess  of,  819 
ligation  of,  818 

removal  of,  Barker's  technic,  818 
resection  of,  817 
Verruca  necrogenica,  194 
Vertebrae,  acute  osteomyelitis  of,  695 
Vertebral  artery,  367 

ligation  of,  368 
Vesical  calculus,  972 
crushing  of,  985 
treatment,  975 
Vesiculitis,  1023 
Vibrione  septique,  44 
Vicious  union,  417 
treatment,  426 
Vienna  paste,  95 
Villous  papillomata,  291 
Virchow's  disease,  403 
law,  265 

sign  in  hereditary  syphilis,  262 
Viscera,  injuries  with  damage  to,  760 
Visceral  syphilis,  252 
Volkmann's  dorsal  splint  for  excision  of 
ankle,  607 
operation,  1033 
Volvulus,  775 
Vomiting  after  anesthetics,  903 

in  anesthesia,  900 
Von    Zeissl's    rules   of    inheritance  of 

syphilis,  260 
Vulcanite  splint,  433 

Wandering  kidney,  948 

spleen,  812 
Wardrop's    operation     for     aneurysm, 

320 
Wart-horn,  291 
Warts,  291 

in  syphilis,  247 

lymphatic,  924 

venereal,  291 
Wasps,  stings  of,  227 
Water  on  the  brain,  674 
Water-bath  in  inflammation,  93 
Watson's   plaster-of- Paris   swing-splint, 

606 
Weavers'  bottom,  626 
Webbed  fingers,  634 
Weir's  method  of  cleansing  hands,  49 
Wens,  300 
Wet  cups,  82 
Wharton's  jelly,  277 
Wheelhouse's  operation,  1019 
White  infarction,  170 

swelling,  196,  514,  524 

thrombus,  168 


Whitehead's  operation  for  excision  of 
tongue,  751 
for  hemorrhoids,  881 
Whitlow,  623.     See  also  Felot?. 
Witzel's  method  for  gastrostomy,  829 
Wolfler-Lucke  metliod  of  gastro-enter- 

ostomy,  833 
Wolfler's  suture,  822,  823 
Wool-sack  cocci,  20 
Wool-sorters'    disease,    230.     See    also 

Anthrax. 
Wounds,  205 

and  injuries  of  heart,  302 

arrest  of  hemorrhage  in,  209 

articular,  540 

by  cannon-balls,  222 

by  small  shot,  222 

cleansing  of,  210 

closure  of,  210 

contused,  215 

of  arteries,  324 
dissection-,  226 
drainage  of,  210 
dressing  of,  210 
gaping,  205 
gunshot,  217 
of  arteries,  326 
of  head,  670 
hemorrhage  in,  205 
incised,  211 

inflicted  in  war,  prevention  of  infec- 
tion in,  225 
in  non-vascular  tissue,  healing  of,  112 
irrigation  of,  52 

apparatus  for,  163 
lacerated,  215 
local  phenomena  of,  205 
loss  of  function  from,  205 
non-penetrating,  of  abdominal    wall, 

765, 
of  abdominal  wall,  765 
of  arteries,  324-326 
of  brain,  669 
of  chest,  730 

of  kidney,  perforating,  951 
of  larynx,  716 
of  liver,  802 

of  mucous  membranes,  236 
of  muscles,  617 
of  nerves,  642 
of  rectum,  888 
of  spinal  cord,  709 
of  spleen,  812 
of  tendons,  620 
of  thyroid  gland,  919 
of  ureter,  952 
of  veins,  326 
pain  in,  205 
poisoned,  225 
punctured,  216 

removal  of  foreign  bodies  from,  209 
rest  in,  211 

retraction  of  edges  of,  205 
scalp-,  658 
septic,  226 


INDEX. 


I  I  I 


Wounds,  shock  from,  205 

subcutaneous,  healing  of,  112 

treatment,  209-211 
Wrist,  deformity  at,  due  to  fracture  of 
radius  at  lower  extremity,  469 

dislocations  of,  568 
Wrist-drop,  454 
Wrist-joint,  amputation  of,  1042 

disease  of,  527 

excision  of,  601 
Wrv-neck.  632.     See  also  Torticollis. 
Wy'eth's  apparatus  for  hip-disease,  523 

bloodless  method  for  amputation  at 
hip-joint,  1054 

pins  in  amputation  at  shoulder-joint, 
1043 


Xanthoma,  271 

A'-ray,  1068.     See  also  Rontgen  rays. 

apparatus  for  locating  foreign  bodies, 
Sweet's,  1073 

"bum,"  1071 

gangrene,  107 1,  1072 

in  diagnosis  of  fractures,  413,  415 

use   of,   in   locating    foreign    bodies, 
1072 

use  of,  in  surgen,',  1077 

Yeasts,  18 

ZOOGLEA,  20 

Zygomatic  arch,  fractures  of,  430 


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Gives  a  Maximum  Amount  of   Matter   in    a    Minimum    Space    eoid    at^  the  Lowest 

Possible  Cost. 

This  Edition  contains  all  the  Latest  Words. 

"  I  must  acknowledge  my  astonishment  at  seeing  how  much  he  has  condensed  \vith:r 
relatively  small  space.  I  find'nothing  to  criticise.  ver>-  much  to  commend,  and  was  interested 
in  finding  some  of  the  new  words  which  are  not  in  other  recent  dictionaries." — RoswELL  Park, 
Professor  of  Principles  and  Practice  of  Surgery  and  Clinical  Surgery,  University  of  BuJ/alo. 

"  I  congratulate  you  upon  giving  to  the  profession  a  dictionan.-  so  compact  in  its  structure, 
and  so  replete  with  information  required  by  the  busy  practitioner  and  student.  It  is  a  necessity 
as  well  as  an  informed  companion  to  ever>'  doctor.  It  should  be  upon  the  desk  of  ever}-  prac- 
titioner and  student  of  medicine."— JOHN  B.  MURPHY,  Professor  of  Surgery  and  Clinical 
Surgery,  Northwestern   University  Medical  School,  Chicago. 

The  American  Pocket  Medical  Dictionary.    '^^tJ^^.°°' 

Edited  bv  W.  A.  Xewmax  Dorlaxd,  ^l.  D.,  Assistant  Obstetrician  to 
the  Hospital  of  the  University  of  Pennsylvania  ;  Fellow  of  the  Amer- 
ican Academy  of  Medicine.  Containing  the  pronunciation  and  defini- 
tion of  the  principal  words  used  in  medicine  and  kindred  sciences,  with 
64  extensive  tables.  Handsomely  bound  in  flexible  leather,  with  gold 
edges.     Price  si-oo  net;  with  thumb  index.  Si. 25   net. 

The  American  Year-Book  qf  Medicine  and  Surgery. 

A  Yearly  Digest  of  Scientific  Progress  and  Authoritative  Opinion  m  all 
branches  of  Medicine  and  Surgerv,  drawn  from  journals,  monographs, 
and  text-books  of  the  leading  American  and  Foreign  authors  and  investi- 
gators. Arranged  with  critical  editorial  comments,  by  eminent  Amer- 
ican specialists,  under  the  editorial  charge  of  George  ]M.  Gould,  M.  D. 
Year-Book  of  1901  in  tn-o  volumes — Yol.  I.  including  General  Medicine; 
Yol.  II.,  General  Surge/y.  Per  volume :  Cloth,  S3. 00  net;  Half  Mo- 
rocco, S3. 75   net.      Sold  l>y  Subscription. 

Abbott  on  Transmissible  Diseases,    second  Edition.  Revised. 

The  Hvgiene  of  Transmissible  Diseases :  their  Causation,  Modes  of 
Dissemination,  and  Methods  of  Prevention.  By  A.  C.  Abbott,  ]SI.  D., 
Professor  of  Hvgiene  and  Bacteriology,  University  of  Pennsylvania. 
Octavo,  351  pages,  with  numerous  illustrations.     Cloth,  S2.50  net. 


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Anders*  Practice  cf  Medicine.       Fifth  Revised  Edition. 

A  Text-Book  of  the  Practice  of  Medicine.  By  James  M.  Anders, 
-  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine,  Medico-Chirurgical  College,  Philadelphia.  Hand- 
some octavo  volume  of  1292  pages,  fully  illustrated.  Cloth,  $5.50  net; 
Sheep  or  Half  Morocco,  $6.50  net. 

Bastin's  Botany. 

Laboratory  Exercises  in  Botany.  By  Edson  S.  Bastin,  M.  A.,  late 
Professor  of  Materia  Medica  and  Botany,  Philadelphia  College  of 
Pharmacy.     Octavo,  536  pages,  with  87  plates.     Cloth,  ^2.00  net. 

Beck  on  Fractures. 

Fractures.  By  Carl  Beck,  M.  D.,  Surgeon  to  St.  Mark's  Hospital  and 
the  New  York  German  Poliklinik,  etc.  With  an  appendix  on  the  Prac- 
tical Use  of  the  Rontgen  Rays.  335  pages,  170  illustrations.  Cloth, 
$3.50  net. 

Beck's  Surgical  Asepsis. 

A  Manual  of  Surgical  Asepsis.  By  Carl  Beck,  M.  D.,  Surgeon  to  St. 
Mark's  Hospital  and  the  New  York  German  Poliklinik,  etc.  306  pages; 
65  text-illustrations  and  12  full-page  plates.     Cloth,  $1.25  net. 

Boisliniere*s    Obstetric  Accidents,   Emergencies,  and 
Operations. 

Obstetric  Accidents,  Emergencies,  and  Operations.  By  L.  Ch.  Bois- 
liniere,  M.  D.,  late  Emeritus  Professor  of  Obstetrics,  St.  Louis  Medical 
College.      381  pages,  handsomely  illustrated.     Cloth,  $2.00  net. 

Bohm,  Davidoff,  and  Huber's  Histology. 

A  Text-Book  of  Human  Histology.  Including  Microscopic  Technic. 
By  Dr.  A.  A.  Bohm  and  Dr.  M.  von  Davidoff,  of  INIunich,  and 
G.  Carl  Huber,  M.  D.,  Junior  Professor  of  Anatomy  and  Director  of 
Histological  Laboratory,  University  of  Michigan.  Handsome  octavo 
of  503  pages,  with  351  beautiful  original  illustrations.     Cloth,  $3.50  net. 

Butler's  Materia  Medica,  Therapeutics,  and  Pharma- 
cology.     Third  Edition,  Revised. 

A  Text-Book  of  Materia  Medica,  Therapeutics,  and  Pharmacology. 
By  George  F.  Butler,  Ph.  G.,  M.  D.,  Professor  of  Materia  Medica  and 
of  Clinical  Medicine,  College  of  Physicians  and  Surgeons,  Chicago. 
Octavo,  874  pages,  illustrated.  Cloth,  $4.00  net;  Sheep  or  Half  M07 
rocco,  $5.00  net. 

Cerna  on  the  Newer  Remedies,    second  Edition,  Revised. 

Notes  on  the  Newer  Remedies,  their  Therapeutic  Applications  and 
Modes  of  Administration.  By  David  Cerna,  M.  D.,  Ph.  D.,  Demon- 
strator of  Physiology,  Medical  Department,  University  of  Texas.  Re- 
written and  greatly  enlarged.    Post-octavo,  253  pages.    Cloth,  $1.00  net. 


13.  <^; 

OF   W.  B.  SAUNDERS   &-    CO. 


Chapin  on  Insanity. 

A  Compendium  of  Insanity.  By  John  B.  Chapin,  M.  D.,  LL.  D., 
Phvsician-in-Chief,  Pennsylvania  Hospital  for  the  Insane ;  Honorary 
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Society  of  Mental  Medicine  of  Belgium,  etc.  i2mo,  234  pages,  illus- 
trated.    Cloth,  $1.25  net. 

Chapman's   Medical    Jurisprudence  and  Toxicology. 

Second  Edition,  Revised. 

Medical  Jurisprudence  and  Toxicology.  By  Henry  C.  Chapman, 
M.  D.,  Professor  of  Institutes  of  Medicine  and  Medical  Jurisprudence, 
Jefferson  Medical  College  of  Philadelphia.  254  pages,  with  55  illus- 
trations and  3  full-page  plates  in  colors.     Cloth,  $1.50  net. 

Church  and  Peterson's  Nervous  and  Mental  Diseases. 

Third  Edition.  Revised  and  Enleirged. 

Ner\'ous  and  Mental  Diseases.  By  Archibald  Church,  M.  D.,  Pro- 
fessor of  Nervous  and  Mental  Diseases,  and  Head  of  the  Neurological 
Department,  Northwestern  University  Medical  School,  Chicago  ;  and 
Frederick  Peterson,  M.  D.,  Chief  of  Clinic,  Nervous  Department, 
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volume  of  875  pages,  profusely  illustrated.  Cloth,  $5.00  net;  Sheep  or 
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Clarkson's  Histology. 

A  Text-Book  of  Histology,  Descriptive  and  Practical.  By  Arthur 
Clarkson,  M.  B.,  C.  M.  Edin.,  formerly  Demonstrator  of  Physiology 
in  the  Owen's  College,  Manchester ;  late  Demonstrator  of  Physiology 
in  Yorkshire  College,  Leeds.  Large  octavo,  554  pages;  22  engravings 
and  174  beautifully  colored  original  illustrations.     Cloth,  $4.00  net. 

Corwin's  Physical  Diagnosis.     Third  Edition,  Revised. 

Essentials  of  Physical  Diagnosis  of  the  Thorax.  By  Arthur  M. 
CoRwiN,  A.M.,  M,  D.,  Instructor  in  Physical  Diagnosis  in  Rush 
Medical  College,  Chicago.     219  pages,  illustrated.     Cloth,  $1.25  net. 

CrOOkshank's    Bacteriology.       Fourth  Edition.  Revised. 

A  Text-Book  of  Bacteriology.  By  Edgar  M.  Crookshank,  M.  B., 
Professor  of  Comparative  Pathology  and  Bacteriology,  King's  College, 
London.  Octavo,  700  pages,  273  engravings  and  22  original  colored 
plates.     Cloth,  $6.50  net;    Half  Morocco,  37.50  net. 

DaCosta'S    Surgery.       Third  Edition,  Revised. 

Modern  Surgery,  General  and  Operative.  By  John  Chalmers  Da 
Costa,  M.  D.,  Professor  of  Principles  of  Surgen,'  and  Clinical  Surgery, 
Jefferson  Medical  College,  Philadelphia  ;  Surgeon  to  the  Philadelphia 
Hospital,  etc.  Handsome  octavo  volume  of  1117  pages,  profusely 
illustrated.     Cloth,  35.00  net;   Sheep  or  Half  Morocco,  36.00   net. 

Enlarged  by  over  200  Pages,  with  more  than  100  New  Illustrations. 


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Davis's  Obstetric  Nursing. 

Obstetric  and  Gynecologic  Nursing.  By  Edward  P.  Davis,  A.  M., 
M.  D.,  Professor  of  Obstetrics  in  Jefferson  Medical  College  and  the 
Philadelphia  Polyclinic ;  Obstetrician  and  Gynecologist  to  the  Phila- 
delphia Hospital.  i2nio  volume  of  400  pages,  fully  illustrated. 
Crushed  Buckram,  $1.75   net. 

DeSchweinitz  on  Diseases  qf  the  Eye.  Third  Edition.  Revised. 

Diseases"  of  the  Eye.  A  Handbook  of  Ophthalmic  Practice.  By  G. 
E.  DE  ScHWEiNiTZ,  M.  D.,  Profcssor  of  Ophthalmology,  Jefferson  Medi- 
cal College,  Philadelphia,  etc.  Handsome  royal  octavo  volume  of  696 
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Dorland's  Dictionaries. 

[See  American  Illustrated  Medical  Dictionary  and  American 
Pocket  Medical  Dictionary  on  page  3.] 

Dorland'S    Obstetrics.       second  Edition,  Revised  and  Greatly  Enlarged. 

Modern  Obstetrics.  By  W.  A.  Newman  Dorland,  M.  D.,  Assistant 
Demonstrator  of  Obstetrics,  University  of  Pennsylvania;  Associate  in 
Gynecology,  Philadelphia  Polyclinic.  Octavo  volume  of  797  pages, 
with  201  illustrations.     Cloth,  ^4.00  net. 

Eichhorst's  Practice  cf   Medicine. 

A  Text-Book  of  the  Practice  of  Medicine.  By  Dr.  Herman  Eichhorst, 
Professor  of  Special  Pathology  and  Therapeutics  and  Director  of  the 
Medical  Clinic,  University  of  Zurich.  Translated  and  edited  by  Augus- 
tus A.  EsHNER,  M.  D.,  Professor  of  Clinical   Medicine,  Philadelphia 

Polyclinic.    Two  octavo  volumes  of  600  pages  each,  over  150  illustrations. 

Prices  per  set:   Cloth,  ^6.00  net;  Sheep  or  Half  Morocco,  ^7.50  net. 

Friedrich  anb  Curtis  on  the  Nose,  Throat,  on?  Ear. 

Rhinology,  Laryngology,  and  Otology,  and  Their  Significance  in  Gen- 
eral Medicine.  By  Dr.  E.  P.  Friedrich,  of  Leipzig.  Edited  by  H. 
HoLBROOK  Curtis,  M.  D.,  Consulting  Surgeon  to  the  New  York  Nose 
and  Throat  Hospital.     Octavo,  348  pages.     Cloth,  ^2.50  net. 

Frothingham*s  Guide  for  the  Bacteriologist. 

Laboratory  Guide  for  the  Bacteriologist.  By  Langdon  Frothingham, 
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Scientific  School,  Yale  University.     Illustrated.     Cloth,  75  cts.  net. 

Garrigues*  Diseases  qf  Women.    Third  Edition,  Revised. 

Diseases  of  Women.  By  Henry  J.  Garrigues,  A.  M.,  M.  D.,  Gyne- 
cologist to  St.  Mark's  Hospital  and  to  the  German  Dispensary,  New 
York  City.  Octavo,  756  pages,  with  367  engravings  and  colored  plates. 
Cloth,  I4.50  net;  Sheep  or  Half  Morocco,  ^5.50  net. 


OF    W.  B.  SAUNDERS   &-    CO. 


Gould  and  Pyle's  Curiosities  qf  Medicine. 

Anomalies  and  Curiosities  of  Medicine.  By  George  M.  Gould,  M.  D., 
and  Walter  L.  Pyle,  M.  D.  An  encyclopedic  collection  of  rare  and 
extraordinary  cases  and  of  the  most  striking  instances  of  abnormality  in 
all  branches  of  Medicine  and  Surgery,  derived  from  an  exhaustive 
research  of  medical  literature  from  its  origin  to  the  present  day, 
abstracted,  classified,  annotated,  and  indexed.  Handsome  octavo 
volume  of  968  pages  ;  295  engravings  and  12  full-page  plates.  Popular 
Edition.      Cloth,  $3.00  net;  Sheep  or  Half  Morocco,  $4.00  net. 

Grafstrom*s  Mechano-Therapy. 

A  Text-Book  of  Mechano-Therapy  (Massage  and  Medical  Gymnastics). 
By  Axel  V.  Grafstrom,  B.  Sc,  M.  D.,  late  House  Physician,  City  Hos- 
pital, Blackwell's  Island,  New  York.  i2mo,  139  pages,  illustrated. 
Cloth,  $1.00  net. 

Griffith    on    the    Baby.       second  Edition,  Revised. 

The  Care  of  the  Baby.  By  J.  P.  Crozer  Griffith,  M.  D.,  Clinical 
Professor  of  Diseases  of  Children,  University  of  Pennsylvania;  Phy- 
sician to  the  Children's  Hospital,  Philadelphia,  etc.  i2mo,  404  pages; 
67  illustrations  and  5  plates.     Cloth,  ^1.50  net. 

Griffith's  Weight  Chart. 

Infant's  Weight  Chart.  Designed  by  J.  P.  Crozer  Griffith,  M.  D., 
Clinical  Professor  of  Diseases  of  Children,  University  of  Pennsylvania. 
25  charts  in  each  pad.     Per  pad,   50  cts.  net. 

Hart's  Diet  in  Sickness  and  in  Health. 

Diet  in  Sickness  and  Health.  By  Mrs.  Ernest  Hart,  formerly  Student 
of  the  Faculty  of  Medicine  of  Paris  and  of  the  London  School  of  Medi- 
cine for  Women ;  with  an  Introduction  by  Sir  Henry  Thompson, 
F.  R.  C.  S.,  M.  D.,  London.      220  pages.     Cloth,  $1.50  net. 

Haynes*  Anatomy. 

A  Manual  of  Anatomy.  By  Irving  S.  Haynes,  M.  D.,  Professor  of 
Practical  Anatomy  in  Cornell  University  Medical  College.  6S0  pages ; 
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Heisier's    Embry0l0g»y.       second  Edition,  Revised, 

A  Text-Book  of  Embryology.  By  John  C.  Heisler,  M.  D.,  Professor 
of  Anatomy,  Medico-Chirurgical  College,  Philadelphia.  Octavo  volum.e 
of  405  pages,  handsomely  illustrated.     Cloth,  $2.50  net. 

Hirst's    Obstetrics.       Third  Edition.  Revised  and  Enlarged. 

A  Text-Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.  D.,  Professor 
of  Obstetrics,  LTniversity  of  Pennsylvania.  Handsome  octavo  volume 
of  873  pages  ;  704  illustrations,  36  of  them  in  colors.  Cloth,  ^5.00  net ; 
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MEDICA  L    P  UBL ICA  TIONS 


Hyde  and  Montgomery  on   Syphilis  and  the  Venereal 

Diseases.       second  Edition,  Revised  and  Greatly  Enlarged. 

Syphilis  and  the  Venereal  Diseases.  By  James  Nevins  Hyde,  M.  D., 
Professor  of  Skin  and  Venereal  Diseases,  and  Frank  H.  Montgomery, 
M.  D.,  Associate  Professor  of  Skin,  Genito-Urinary,  and  Venereal  Dis- 
eases in  Rush  Medical  College,  Chicago,  111.  Octavo,  594  pages, 
profusely  illustrated.     Cloth,  ^4.00  net. 

^e  International  Text- Book  of  Surgery,     in  Two  volumes. 

By  American  and  British  Authors.  Edited  by  J.  Collins  Warren, 
M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.),  Professor  of  Surgery,  Harvard  Medi- 
cal School,  Boston ;  and  A.  Pearce  Gould,  M.  S.,  F.  R.  C.  S.,  Lecturer 
on  Practical  Surgery  and  Teacher  of  Operative  Surgery,  Middlesex 
Hospital  Medical  School,  London,  Eng.  Vol.  L  Genera/  Surgery. — 
Handsome  octavo,  947  pages,  with  458  beautiful  illustrations  and  9 
lithographic  plates.  Vol.  IL  Special  or  Regional  Surgery. — Handsome 
octavo,  1072  pages,  w^ith  471  beautiful  illustrations  and  8  lithographic 
plates.  Sold  by  Subscription.  Prices  per  volume:  Cloth,  $5.00  net; 
Sheep  or  Half  Morocco,  ^6.00  net. 

"  It  is  the  most  valuable  work  on  the  subject  that  has  appeared  in  some  years.  The  clini- 
cian and  the  pathologist  have  joined  hands  in  its  production,  and  the  result  must  be  a  satis- 
faction to  the  editors  as  it  is  a  gratification  to  the   conscientious  reader." — Antials  of  Surgery. 

"  This  is  a  work  which  comes  to  us  on  its  own  intrinsic  merits.  Of  the  latter  it  has  very- 
many.  The  arrangement  of  subjects  is  excellent,  and  their  treatment  by  the  different  authors 
is  equally  so.  What  is  especially  to  be  recommended  is  the  painstaking  endeavor  of  each 
writer  to  make  his  subject  clear  and  to  the  point.  To  this  end  particularly  is  the  technique 
of  operations  lucidly  described  in  all  necessary  detail.  And  withal  the  work  is  up  to  date  in 
a  very  remarkable  degree,  many  of  the  latest  operations  in  the  different  regional  parts  of  the 
body  being  given  in  full  details.  There  is  not  a  chapter  in  the  work  from  which  the  reader 
may  not  learn  something  new." — Medical  Record,  New  York. 

Jackson's  Diseases  qf  the  Eye. 

A  Manual  of  Diseases  of  the  Eye.  By  Edward  Jackson,  A.  M.,  M.  D., 
Emeritus  Professor  of  Diseases  of  the  Eye,  Philadelphia  Polyclinic  and 
College  for  Graduates  in  Medicine.  i2mo  volume  of  535  pages,  with 
178  illustrations,  mostly  from  drawings  by  the  author.    Cloth,  $2.50  net. 

Keatin^'s  Life  Insurance. 

How  to  Examine  for  Life  Insurance.  By  John  M.  Keating,  M.  D., 
Fellow  of  the  College  of  Physicians  of  Philadelphia ;  Ex-President  of  the 
Association  of  Life  Insurance  Medical  Directors.  Royal  octavo,  211 
pages.     With  numerous  illustrations.     Cloth,  $2.00  net. 

Keen  on  the  Surgery  of  Typhoid  Fever. 

The  Surgical  Complications  and  Sequels  of  Typhoid  Fever.  By  Wm. 
W.  Keen,  M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.),  Professor  of  the  Principles 
of  Surgery  and  of  Clinical  Surgery,  Jefferson  Medical  College,  Phila- 
delphia, etc.    Octavo  volume  of  386  pages,  illustrated.    Cloth,  $3.00  net. 

Keen's    Operation    Blank.       second  Edition,  Revised  Form. 

An  Operation  Blank,  with  Lists  of  Instruments,  etc.,  Required  in  Vari- 
ous Operations.  Prepared  by  W.  W.  Keen,  M.  D.,  LL.  D.,  F.  R.  C.  S. 
(Hon.),  Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery, 
Jefferson  Medical  College,  Philadelphia.  Price  per  pad,  blanks  for  fifty 
operations,  50  cts.  net. 


OF    IV.  13.  SAUNDERS   a-    CO. 


Kyle  on  the  Nose  and  Throat,     second  Edition. 

Diseases  ol'  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.  D.,  CHnical 
Professor  of  laryngology  and  Rhinology,  Jefferson  Medical  College, 
Philadelphia.  Octavo,  646  pages;  over  150  illustrations  and  6  litho- 
graphic plates.     Cloth,  $4.00  net;  Sheep  or  Half  Morocco,  I5.00  net. 

Laine's  Temperature  Chart. 

Temperature  Chart.  Prepared  by  D.  T.  Laine,  M.  D.  Size  8x131^ 
inches.  A  conveniently  arranged  Chart  for  recording  Temperature, 
with  columns  for  daily  amounts  of  Urinary  and  Fecal  Excretions,  Food, 
Remarks,  etc.  On  the  back  of  each  chart  is  given  the  Brand  treatment 
of  Typhoid  Fever.     Price,  per  pad  of  25  charts,  50  cts.  net. 

Levy,  Klemperer,  arid  Eshner*s  Clinical  Bacteriology. 

The  Elements  of  Clinical  Bacteriology.  By  Dr.  Ernst  Levy,  Pro- 
fessor in  the  University  of  Strasburg,  and  Felix  Klemperer,  Privat- 
docent  in  the  University  of  Strasburg.  Translated  and  edited  by 
Augustus  A.  Eshner,  M.  D.,  Professor  of  Clinical  Medicine,  Philadel- 
phia Polyclinic.     Octavo,  440  pages,  fully  illustrated.     Cloth,  I2.50  net. 

Lockwood's  Practice  of  Medicine.         RevfseTand^EJilSed 

A  Manual  of  the  Practice  of  Medicine.  By  George  Roe  Lockwood, 
M.  D.,  Professor  of  Practice  in  the  Woman's  Medical  College  of  the 
New  York  Infirmary,  etc. 

Long's  Syllabus  of  Gynecology. 

A  Syllabus  of  Gynecology,  arranged  in  Conformity  with  "An  American 
Text-Book  of  Gynecology."  By  J.  W.  Long,  M.  D.,  Professor  of  Dis- 
eases of  Women  and  Children,  Medical  College  of  Virginia,  etc.  Cloth, 
interleaved,  $1.00  net. 

Macdonald's  Surgical  Diagnosis  and  Treatment. 

Surgical  Diagnosis  and  Treatment.  By  J.  W.  Macdonald,  M.  D. 
Edin.,  F.  R.  C.  S.  Edin.,  Professor  of  Practice  of  Surgery  and  Clinical 
Surgery,  Hamline  University.  Handsome  octavo,  800  pages,  fully  illus- 
trated.    Cloth,  ;^5.oo  net;  Sheep  or  Half  Morocco,  |6.oo  net. 

Mallory  and  Wright's  Pathological  Technique. 

Second  Edition,  Revised. 

Pathological  Technique.  A  Practical  Manual  for  Laboratory  Work  in 
Pathology,  Bacteriology,  and  Morbid  Anatomy,  with  chapters  on  Post- 
Mortem  Technique  and  the  Performance  of  Autopsies.  By  Frank  B. 
Mallory,  A.  M.,  M.  D.,  Assistant  Professor  of  Pathology,  Harvard 
University  Medical  School,  Boston  ;  and  James  H.  Wright,  A.  M., 
M.  D.,  Instructor  in  Pathology,  Harvard  University  Medical  School, 
Boston. 

McFarland's  Pathogenic  Bacteria.  '^'StbyovTr/ooTiel" 

Text-Book  upon  the  Pathogenic  Bacteria.  By  Joseph  McFarland, 
M.  D.,  Professor  of  Pathology  and  Bacteriology,  Medico-Chirurgical 
College  of  Philadelphia,  etc.  Octavo  volume  of  621  pages,  finely  illus- 
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Mei^s  on  Feeding  in  Infancy. 

Feeding  in  Early  Infancy.  By  Arthur  V.  Meigs,  M.  D.  Bound  in 
limp  cloth,  flush  edges,  25  cts.  net. 

Moore's  Orthopedic  Surgery. 

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fessor of  Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery,  Uni- 
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Morten's  Nurses*  Dictionary. 

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Abbreviations ;  of  the  Instruments,  Drugs,  Diseases,  Accidents,  Treat- 
ments^ Operations,  Foods,  Appliances,  etc.  encountered  in  the  ward  or 
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Nancrede*s  Anatomy  and  Dissection.    Fourth  Edition. 

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gery, University  of  Michigan,  Ann  Arbor.  Post-octavo,  500  pages,  with 
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Norris*s  Syllabus  (^  Obstetrics.    Third  Edition.  Revised. 

Syllabus  of  Obstetrical  Lectures  in  the  Medical  Department  of  the 
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rics, University  of  Pennsylvania.  Crown  octavo,  222  pages.  Cloth, 
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Ogden  on  the  Urine. 

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Raymond's  Physiology.    Revise/»„TG,f.^Eii.r,ed. 

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Professor  of  Physiology  and  Hygiene  and  Lecturer  on  Gynecology  in 
the  Long  Island  College  Hospital. 

Salinger  and  Kalteyer's  Modern  Medicine. 

Modern  Medicine.  By  Julius  L.  Salinger,  M.  D.,  Demonstrator  of 
Clinical  Medicine,  Jefferson  Medical  College  ;  and  F.  J.  Kalteyer, 
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College.     Handsome  octavo,  801  pages,  illustrated.     Cloth,  ^4.00  net, 

Saundby*s  Renal  ar^  Urinary  Diseases. 

Lectures  on  Renal  and  Urinary  Diseases.  By  Robert  Saundby,  M.  D. 
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Saunders*  Medical  Hand- Atlases. 

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Senn*s  Genito- Urinary  Tuberculosis. 

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Senn*s  Practical  Surgery. 

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fessor of  the  Practice  of  Surgery  and  of  Clinical  Surgery,  Rush  Medical 
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of  Clinical  Surgery,  Rush  Medical  College,  Chicago.     Cloth,  $1.50  net. 

Senn*S    Tumors.       second  Edition.  Revised. 

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Starr's  Diets  for  Infants  and  Children. 

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Stengel  and  White  on  the  Blood. 

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OF   IK  B.  SAUNDERS   6-    CO. 


13 


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Stewart's    Physiology.       Fourth  Edition,  Revised. 

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Stoney's  Materia  Medica  for  Nurses. 

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StOney*S    Nursing.       second  Edition,  Revised. 

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A.  M.  Stoney,  late  Superintendent  of  the  Training-School  for  Nurses, 
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Stoney*s  Surgical  Technic  for  Nurses. 

Bacteriology  and  Surgical  Technic  for  Nurses.  By  Emily  A.  M.  Stoney, 
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Thomas's    Diet    Lists.       second  Edition.  Revised. 

Diet  Lists  and  Sick-Room  Dietary.  By  Jerome  B.  Thomas,  M.  D., 
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M.  D.  ,  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Phila- 
delphia. 

Van  Valzah  and  Nisbet*s  Diseases  qf  the  Stomach. 

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fessor of  General  Medicine  and  Diseases  of  the  Digestive  System  and 
the  Blood,  New  York  Polyclinic ;  and  J.  Douglas  Nisbet,  M.  D., 
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System  and  the  Blood,  New  York  Polyclinic.  Octavo  volume  of  674 
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14  MEDICAL   PUBLICATIONS. 

Vecki*S    Sexual    Impotence.        second  Edition,  Revised. 

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Demi-octavo,  291  pages.     Cloth,  ^2.00  net. 

VierOrdt'S    Medical    Diagnosis.       Fourth  Edition,  Revised. 

Medical  Diagnosis.  By  Dr.  Oswald  Vierordt,  Professor  of  Medicine, 
University  of  Heidelberg.  Translated,  with  additions,  from  the  fifth 
enlarged  German  edition,  with  the  author's  permission,  by  Francis  H. 
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Watson's  Handbook  for  Nurses. 

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Edition,  under  supervision  of  A.  A.  Stevens,  A.  M.,  M.  D.,  Lecturer 
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Warren's  Surgical  Pathology,     second  Edition. 

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Medical  School.  Handsome  octavo,  873  pages;  136  relief  and  litho- 
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1.  Essentials  of  Physiology.     By  Sidney  Budgett,  M.  D.     A  N'etv  Work. 

2.  Essentials  of  Surgery.     By  Edward  Martin,  M.D.     Seventh  edition,  revised,  with 

an  Appendix  and  a  chapter  on  Appendicitis. 

3.  Essentials  of  Anatomy.     By  Charles   B.    Nancrede,   AI.  D.     Sixth  edition,  thor- 

oughly revised  and  enlarged. 

4.  Essentials  of  Medical  Chemistry,  Organic  and  Inorganic.     By  Lawrence  Wolff, 

!M.  D.      Filth  edition,  revised. 

5.  Essentials  of  Obstetrics.     By  W.  E.asterly  Ashton,  M.D.     Fourth  edition,  revised 

and  enhirged. 

6.  Essentials  of  Pathology  and  Morbid  Anatomy.     By  F.  J.  Kalteyer,  M.  D.     In 

preparation. 

7.  Essentials  of  Materia  Medica,  Therapeutics,  zoid  Prescription-Writing.    By  Henry 

Morris,  M.  D.     Fifth  edition,  levised. 

8.  9.    Essentials  of  Practice  of  Medicine.     By  Henry  Morris,  M.  D.     An  Appendix 

on  Urine  Examination.  By  Lawrence  Wolff,  M.  D.  Third  edition,  enlarged 
by  some  300  Essential  Formulse,  selected  from  eminent  authorities,  by  Wm.  AL 
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11.  Essentials  of  Diseases  of  the  Skin.     By  Henry  W.  Stelwagon,  M.  D.     Fourth 

edition,  revised  and  enlarged. 

12.  Essentials  of  Minor  Surgery,  Baoidaging,  £md  Venereal    Diseases.     By  Ed\vard 

M.A.RTI.N,  AL  D.     Second  edition,  revised  and   enlarged. 

13.  Essentials    of    Legal    Medicine,   Toxicology,    and    Hygiene.     This   volume   is   at 

present  out  of  print. 

14.  EssentizJs  of  Diseases  of  the  Eye.     By  Edward  Jackson,  M.D.     Third  edition, 

revised  and  enlarged. 

15.  Essentials  of  Diseases  of  Children.    By  William  M.  Powell,  M.  D.    Third  edition. 

16.  Essentials    of    Examination    of    Urine.     By   Lawrence   Wolff,   AL  D.      Colored 

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17.  Essentials  of  Diagnosis.     By  S.   Solis-Cohen,   M.  D.,   and   A.   A.  Eshner,  M.  D. 

Second  edition,  thoroughly  revised. 

18.  Essentials    of    Practice    of    Pharmacy.     By  Lucius    E.    Sayre.     Second   edition, 

revised  and  enlarged. 

19.  Essentials  of  Diseases  of  the  Nose  and  Throat.     By  E.  B.  Gleason,  AL  D.     Third 

ediiion,  revised  and  enlarged. 

20.  Essentials  of  Bacteriology.     By  M.  V.  Ball,  AL  D.     Fourth  edition,  revised. 

21.  Essentials  of  Nervous  Diseases  and  Inseuiity.     By  John  C.  Shaw,  M.D.     Third 

edition,  revised. 

22.  Essentials  of    Medical    Physics.     By  Fred  J.   Brockway,  j\L  D.     Second  edition, 

revised. 

23.  Essentials  of  Medical  Electricity.     By  David  D.  Stewart.  M.  D.,  and  Edward 

S.  L.A^VRANCE,  IsL  D. 

24-    Essentials  of  Diseases  of  the  Ear.     By  E.  B.   Gleason,   M.  D.     Second   edition, 
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25.    Essentials  of  Histology.     By  Louis  Leroy,  M.  D.     With  73  original  illustrations. 


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15 


Saunders'  Medical    Hand-Atlases. 

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Atlas  and  Epitome  of  Diseases  of  the  Larynx. 

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Atlas   and   Epitome   of    Syphilis    and   the   Venereal 
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Bangs,  M.  D.,  Professor  of  Genito-Urinary  Surgery,  University  and 
Bellevue  Hospital  Medical  College,  New  York.  With  71  colored 
plates,  16  illustrations,  and  122  pages  of  text.     Cloth,  ^3.50  net. 

Atlas  and  Epitome  of  External  Diseases  of  the  Eye. 

By  Dr.  O.  Haab,  of  Zurich.  Edited  by  G.  E.  de  Schweinitz,  M.  D., 
Professor  of  Ophthalmology,  Jefferson  Medical  College,  Philadelphia. 
With  76  colored  illustrations  on  40  plates  and  228  pages  of  text. 
Cloth,  $3.00  net. 

Atlas  and  Epitome  of  Skin  Diseases. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited  by  Henry  W.  Stel- 
WAGON,  M.  D.,  Clinical  Professor  of  Dermatology,  Jefferson  Medical 
College,  Philadelphia.  With  63  colored  plates,  39  half-tone  illustra- 
tions, and  200  pages  of  text.     Cloth,  $3.50  net. 

Atlas  and  Epitome  of  Special  Patholog(ical  Histolog(y. 

By  Dr.  H.  Durck,  of  Munich.  Edited  by  Ludwig  Hektoen  M.  D., 
Professor  of  Pathology,  Rush  Medical  College,  Chicago.  In  Two  Parts. 
Part  I.  Ready,  including  Circulatory,  Respiratory,  and  Gastro-intestinal 
Tract,  120  colored  figures  on  62  plates,  158  pages  of  text.  Part  IL 
Ready  Shortly.     Price  of  Part  I.,  $3.00  net. 

16 


Saunders'  Medical   Hand-Atlases. 


VOLUMES   JUST   ISSUED. 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents. 

By  Dr.  Ed.  Golebiewski,  of  Berlin.  Translated  and  edited  with  addi- 
tions by  Pearce  Bailey,  M.  D.,  Attending  Physician  to  the  Department 
of  Corrections  and  to  the  Almshouse  and  Incurable  Hospitals,  New 
York.  With  40  colored  plates,  143  text-illustrations,  and  600  pages 
of  text.     Cloth,  $4.00  net. 

Atlas  and  Epitome  of  Gynecology. 

By  Dr.  O.  Shaeffer,  of  Heidelberg.  Fi-om  the  Second  Revised  Ger- 
man Edition.  Edited  by  Richard  C.  Norris,  A.  M.,  M.  D.,  Gyne- 
cologist to  the  Methodist  Episcopal  and  the  Philadelphia  Hospitals; 
Surgeon-in-Charge  of  Preston  Retreat,  Philadelphia.  With  90  colored 
plates,  65  text-illustrations,  and  308  pages  of  text.     Cloth,  ^3.50  net. 

Atlas  and  Epitome  of  the  Nervous  System  and  its 
Diseases. 

By  Professor  Dr.  Chr.  Jakob,  of  Erlangen.  From  the  Second  Re- 
vised and  Fnlai'ged  German  Edition.  Edited  by  Edward  D.  Fisher, 
M.  D.,  Professor  of  Diseases  of  the  Nervous  System,  University  and 
Bellevue  Hospital  Medical  College,  New  York.  With  83  plates  and.a 
copious  text.     Cloth,  $3.50  net. 

Atlas  and  Epitome  of  Labor  and  Operative  Obstetrics. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Fifth  Revised  and 
Enlarged  German  Edition.  Edited  by  J.  Clifton  Edgar,  M.  D., 
Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University 
Medical  School.      With  126  colored  illustrations.      Cloth,  $2.00  net. 

Atlas    and     Epitome    of    Obstetric     Diagnosis    and 
Treatment. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Second  Revised  and  En- 
larged German  Edition.  Edited  by  J.  Clifton  Edgar,  M.  D.,  Professor 
of  Obstetrics  and  Clinical  Midwifery,  Cornell  University  Medical  School. 
72  colored  plates,  text-illustrations,  and  copious  text.      Cloth,  $3.00  net. 

Atlas   and   Epitome   of   Ophthalmoscopy  and    Oph- 
thalmoscopic  Diagnosis. 

By  Dr.  O.  Haab,  of  Zurich.  From  the  Third  Revised  and  Enlarged 
German  Editio?i.  Edited  by  G.  E.  de  Schweinitz,  M.  D.,  Professor 
of  Ophthalmology,  Jefferson  Medical  College,  Philadelphia.  With  152 
colored  figures  and  82  pages  of  text.      Cloth,  $3.00  net. 

Atlas  and  Epitome  of  Bacteriology. 

Including  a  Text-Book  of  Special  Bacteriologic  Diagnosis.  By  Prof. 
Dr.  K.  B.  LeHiMann  and  Dr.  R.  O.  Neumann,  of  Wurzburg.  From  the 
Second  Revised  Gei'man  Edition.  Edited  by  George  H.  Weaver,  M.  D., 
Assistant  Professor  of  Pathology  and  Bacteriology,  Rush  Medical  College, 
Chicago.  Two  volumes  with  over  600  colored  lithographic  figures, 
numerous  text-illustrations,  and  500  pages  of  text. 


ADDITIONAL   VOLUMES   IN   PREPARATION. 

17 


NOTHNAGEL*S   ENCYCLOPEDIA 

OF 

PRACTICAL   MEDICINE 

Edited  by  ALFRED   STENGEL.  M.  D. 

-    Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania;  Visiting 
Physician  to  the  Pennsylvania  Hospital 

IT  is  universally  acknowledged  that  the  Germans  lead  the  world  in  Internal 
Medicine  ;  and  of  all  the  German  works  on  this  subject,  Xothnagel's  "Ency- 
clopedia of  Special  Pathology  and  Therapeutics"  is  conceded  by  scholars  to 
be  without  question  the  best  System  of  Medicine  in  existence.  So  necessar>' 
is  this  book  in  the  study  of  Internal  ^Medicine  that  it  comes  largely  to  this  country 
in  the  original  German.  In  view  of  these  facts,  ^lessrs.  W.  B.  Saunders  &  Com- 
pany have  arranged  with  the  publishers  to  issue  at  once  an  authorized  edition 
of  this  great  encyclopedia  of  medicine  in  English. 

For  the  present  a  set  of  some  ten  or  twelve  volumes,  representing  the  most 
practical  part  of  this  encyclopedia,  and  selected  with  especial  thought  of  the  needs 
of  the  practical  physician,  will  be  published.  The  volumes  will  contain  the  real 
essence  of  the  entire  work,  and  the  purchaser  will  therefore  obtain  at  less  than 
half  the  cost  the  cream  of  the  original.  Later  the  special  and  more  strictly 
scientific  volumes  will  be  offered  from  time  to  time. 

The  work  will  be  translated  by  men  possessing  thorough  knowledge  of  both 
English  and  German,  and  each  volume  will  be  edited  by  a  prominent  specialist 
on  the  subject  to  which  it  is  devoted.  It  will  thus  be  brought  thoroughly  up  to 
date,  and  the  American  edition  will  be  more  than  a  mere  translation  of  the  Ger- 
man ;  for,  in  addition  to  the  matter  contained  in  the  original,  it  will  represent  the 
very  latest  views  of  the  leading^  American  specialists  in  the  various  departments 
of  Internal  Medicine.  The  w^hole  System  will  be  under  the  editorial  super- 
vision of  Dr.  Alfred  Stengel,  who  will  select  the  subjects  for  the  American  edition, 
and  will  choose  the  editors  of  the  different  volumes. 

Unlike  most  encyclopedias,  the  publication  of  this  work  will  not  be  extended 
over  a  number  of  years,  but  five  or  six  volumes  will  be  issued  during  the  coming 
year,  and  the  remainder  of  the  series  at  the  same  rate.  Moreover,  each  volume 
will  be  revised  to  the  date  of  its  publication  by  the  American  editor.  This  will 
obviate  the  objection  that  has  heretofore  existed  to  systems  published  in  a  number 
of  volumes,  since  the  subscriber  will  receive  the  completed  work  while  the  earlier 
volumes  are  still  fresh. 

The  usual  method  of  publishers,  when  issuing  a  work  of  this  kind,  has  been 
to  compel  physicians  to  take  the  entire  System.  This  seems  to  us  in  many  cases 
to  be  undesirable.  Therefore,  in  purchasing  this  encyclopedia,  phj-sicians  will  be 
given  the  opportunity'  of  subscribing  for  the  entire  System  at  one  time ;  but  any 
single  volume  or  any  number  of  volumes  may  be  obtained  by  those  who  do  not 
desire  the  complete  series.  This  latter  method,  while  not  so  profitable  to  the  pub- 
lisher, offers  to  the  purchaser  many  advantages  which  will  be  appreciated  by  those 
who  do  not  care  to  subscribe  for  the  entire  work  at  one  time. 

This  American  edition  of  Xothnagel's  Encyclopedia  will,  without  question, 
form  the  greatest  System  of  Medicine  ever  produced,  and  the  publishers  feel  con- 
fident that  it  will  meet  with  general  favor  in  the  medical  profession. 


NOTHNAGEL^S  ENCYCLOPEDIA 

VOLUMES  JUST  ISSUED  AND  IN  PRESS 


VOLUME  I 
Editor,  William  Osier,  M.  D.,  F.  R.  C.  P. 

Professor  of  Mcdicir.e  ir.  Jolnis  Hopkins 
University 

CONTENTS 
Typhoid  Fever.     By  Dr.  H.  Ccrschmann, 
of  Leipsic.     Typhus  Fever.     By  Dr.  H. 
CuRSCHMANX,  of  Leipsic. 

Handsome  octavo  volume  of  about  600  pages. 
Just  Issued 


VOLUME  n 

Editor,  Sir  J.  W.  Moore,  B.  A.,  M.D., 
F.R.C.P.L,  of  Dublin 

Projessor  of  Practice  of  ^ledicine,  Royal  College 
of  Surgeons  in  Ireland 

CONTENTS 

Erysipelas  and  Erysipeloid.  By  Dr.  H.  Lex- 
HARTz.  of  HamDurg.  CholeraAsiatica  and 
Chokra  Nostras.  By  Dr.  K.  ^■ox  Lieber- 
MEISTER,  of  Tubingen.  Whoooing  Cough 
and  Hay  Fever.  By  Dr.  G.  Stxker.  of 
Giessen.  Varicella.  By  Dr.  Th.  vox  Jcr- 
gexsex,  of  Tiibingen.  Variola  including 
Vaccinationi.  Ev  Dr.  H.  Immermanx,  of 
Basle. 

Haudsome  octavo  volume  of  over  700  pages. 
fujt  Issued 


VOLUME  vn 

Editor,  John  H.  Musser,  M.  D. 

Professor  of  Clinical  Medicine ,  University  of 
Pennsylvania 

CONTENTS 

Diseases  of  the  Bronchi.  By  Dr.  Y.  A.  Hoff- 
MAXN,  of  Leipsic.  Diseases  of  the  Pleura. 
By  Dr.  Rosexeach,  of  Berlin.  Pneumonia. 
Bv  Dr.  E.  Aufrecht.  of  Magdeburg. 


VOLUME   \'TII 
Editor,  Charles  G.  Stockton,  M.  D. 

Professor  of  Medicine,  University  of  Buffalo 

CONTENTS 

Diseases  of  the  Stomach.    By  Dr.  F.  Riegel, 

cf  Gieisen. 


VOLUTVIE  EX 
Editor,  Frederick  A.  Packard,  M.  D. 

Physician  to  the  Pennsylvania  Hospital  and  to  the 
Ckildren' s  Hospital ,  Philadelphia 

CONTENTS 

Diseases  of  the  Liver.   By  Drs.  H.  Quixcke 
and  G.  Hoppe-Seyler,  of  Kiel. 


VOLUME  m 
Editor,  William  P.  Northrup,  M.D. 

Professor  cf  Pediatrics,  University  and  Bellevue 
Medical  College 

CONTENTS 

Measles.  By  Dr.  Th.  vox  Jurgexsex,  of 
Tiibingen.  Scarlet  Fever.  By  the  same 
author.     Rotheln,    By  the  same  author. 


VOLUME  X 
Editor,  Reginald  H.  Fitz,  A.M.,  M.  D. 

Hersey  Professor  of  the  Theory  and  Practice 
of  Physic,  Harvard  University 

CONTENTS 

Diseases  of  the  Pancreas.  By  Dr.  L.  Oser. 
of  Vienna.  Diseases  of  the  Suprarenals. 
Bv  Dr.  E.  Neusser,  of  Vienna. 


VOLUME  VI 
Editor,  Alfred  Stengel,  M.D. 

Professor  of  Clinical  Medicine ,  University  of 
Penjisylvania 

CONTENTS 

Anemia.  By  Dr.  P.  Ehrlich,  of  Frankfort- 
on-the-Main,  and  Dr.  A.  L.\Zakus,  of  Char- 
lottenburg.  Chlorosis.  By  Dr.  K.  vox 
NooRDEX.  of  Frankfort-on-the-Main.  Dis- 
eases of  the  Spleen  and  Hemorrhagic 
Diathesis.   By  Dr.  M.  Littex,  of  Berlin. 


VOLUMES  rV,  V,  and  XI 
Editors  announced  later 

ol.  IV. — Influenza  and  Dengue.  By  Dr.  O. 
Leichtexsterx,  of  Cologne.  MalarialDis- 
eases.  By  Dr.  J.  Maxxaberg.  oi  Vienna, 
ol.  ^  - — Tuberculosis  and  Acute  General 
Miliary  Tuberculosis.  Bv  Dr.  G.  Corxet, 
of  Berlin. 

ol.  XT. — Diseases  of  the  Intestines  and 
Peritoneum.  By  Dr.  H.  Xothxagel, 
of  Vienna. 


19 


CLASSIFIED   LIST 

OF  THE 

MEDICAL    PUBLICATIONS 


OF 


W.  B.  SAUNDERS  O  COMPANY 


ANATOMY,  EMBRYOLOGY, 
HISTOLOGY. 

Bbltm,    Davidofif,    and    Huber— A  Text- 
Book  of  Histology, 

Clarkson — A  Text-Book  of  Histology, 

Haynes — A  Manual  of  Anatomy,    .    . 

Heisler — A  Text-Book  of  Embryology, 

Leroy — Essentials  of  Histology,  .    .    . 

Nancrede — Essentials  of  Anatomy,  . 

Nancrede — Essentials    of    Anatomy 
Manual  of  Practical  Dissection,  . 


and 


BACTERIOLOGY. 

Ball — Essentials  of  Bacteriology 15 

FrotMngham — Laboratory  Guide 6 

Gorham — Laboratory  Course  in  Bacteri- 
ology   22 

Lelnnann.  and  Neumann — Atlas  of  Bacte- 
riology,      17 

Levy  and  Klemperer's  Clinical  Bacter- 

ology g 

Mallory  and  Wright— Pathological  Tech- 
nique,    9 

McFarland — Pathogenic  Bacteria 9 

CHARTS,  DIET-LISTS,  ETC. 

Griffith— Infant's  Weight  Chart, 7 

Hart — Diet  in  Sickness  and  in  Health,  .    .  7 

Keen — Operation  Blank, 8 

Laine — Temperature  Chart, 9 

Meigs — Feeding  in  Early  Infancy 10 

Starr — Diets  for  Infants  and  Children,  .    .  12 

Thomas — Diet-Lists, 13 

CHEMISTRY  AND  PHYSICS. 

Brockway — Essentials  of  Medical  Physics,  15 

Wolff — Essentials  of  Medical  Chemistry,  .  15 

CHILDREN. 
An  American  Text-Book  of  Diseases  of 

Children, i 

Griffith— Care  of  the  Baby 7 

Griffith— Infant's  Weight  Chart 7 

Meigs— Feeding  in  Early  Infancy,  ....  10 

Powell — Essentials  of  Diseases  of  Children,  15 

Starr— Diets  for  Infants  and  Children,  .    .  12 

DIAGNOSIS. 

Cohen  and  Eshner — Essentials  of  Diag- 
nosis   15 

Corwin — Physical  Diagnosis 5 

Vierordt — Medical  Diagnosis 14 

DICTIONARIES. 

The  American  Illustrated  Medical  Dic- 
tionary   3 

The  American  Pocket  Medical  Dictionary,  3 

Morten — Nurses'  Dictionary, 10 


EYE,  EAR,  NOSE,  AND  THROAT. 

An  American  Text-Book  of  Diseases  of 

the  Eye,  Ear,  Nose,  and  Throat i 

De  Schweinitz — Diseases  of  the  Eye,    .    .  6 
Friedrich  and  Curtis — Rhinology,  Laryn- 
gology and  Otology 6 

Gleason — Essentials  of  Diseases  of  the  Ear,  15 

Gleason — Ess.  of  Dis.  of  Nose  and  Throat,  15 

Gradle — Ear,  Nose,  and  Throat, za 

Griinwald   and    Grayson — Atlas  of  Dis- 
eases of  the  Larynx 16 

Haab  and  De  Schweinitz^Atias  of  Exter- 
nal Diseases  of  the  Eye 16 

Haab  and  De  Schweinitz— Atlas  of  Oph- 
thalmoscopy,         i    .    .  17 

Jackson — Manual  of  Diseases  of  the  Eye,  8 

Jackson — Essentials   of   Diseases  of   Eye,  15 

Kyle — Diseases  of  the  Nose  and  Throat,  .  9 

GENITO-URINARY. 

An  American  Text-Book  of  Genito-TJri- 

nary  and  Skin  Diseases 2 

Hyde  and  Montgomery — Syphilis  and  the 

Venereal  Diseases 8 

Martin — Essentials     of    Minor     Surgery, 

Bandaging,  and  Venereal  Diseases,  ...  15 
Mracek  and  Bangs — Atlas  of  Syphilis  and 

the  Venereal  Diseases 16 

Saundby — Renal  and  Urinary  Diseases,  .  .  11 
Senn — Genito-Urinary  Tuberculosis,  ...  12 
Vecki — Sexual  Impotence, 14 

GYNECOLOGY. 

American  Text-Book  of  Gynecology,    .   .  2 

Cragin — Essentials  of  Gynecology,  ....  15 

Garrigues — Diseases  of  Women 6 

Long — Syllabus  of  Gynecology 9 

Penrose — Diseases  of  Women .  10 

Pryor — Pelvic  Inflammations 11 

Sohaeffer  &  Norris — Atlas  of  Gynecology,  17 

HYGIENE. 
Abbott — Hygiene  of  Transmissible  Diseases    3 

Bergey — Principles  of  Hygiene 22 

Pyle — Personal  Hygiene, 11 

MATERIA  MEDICA,  PHARMACOL- 
OGY, AND  THERAPEUTICS. 

American  Text-Book  of  Therapeutics,  .  .  i 
Butler — Text-Book    of    Materia    Medica, 

Therapeutics,  and  Pharmacology,    ...  4 

Morris — Ess.  of  M.  M.  and  Therapeutics,  15 

Saunders'  Pocket  Medical  Formulary,  .    .  11 

Sayre — Essentials  of  Pharmacy 15 

Sollmann— Text- Book  of  Pharmacology,  .  22 

Stevens — Manual  of  Therapeutics,    ...  13 

Stoney — Materia  Medica  for  Nurses,    .    .  13 

Thornton — Prescription- Writing 13 


MEDICAL  PUBLICATIONS  OF  W.  B.  SAUNDERS  6-  CO. 


MEDICAL  JURISPRUDENCE  AND 
TOXICOLOGY. 

Chapman — M  ed  i  c  a  1  Jurisprudence  and 
Toxicology 5 

Golebiewski  and  Bailey— Atlas  of  Dis- 
eases Caused  by  Accidents, 17 

Hofmann  and  Peterson — Atlas  of  Legal 
Medicine i6 

NERVOUS  AND  MENTAL 
DISEASES,  ETC. 

Brower — Manual  of  Insanity 22 

Chapin — Connpendium  of  Insanity,    ...  5 
Cliurcll  and  Peter  son — Nervous  and  Men- 
tal Diseases 5 

Jakob  &  Fisher — Atlas  of  NervousSystem,  17 
Shaw — Essentials  of  Nervous  Diseases  and 

Insanity 15 

NURSING. 

Davis — Obstetric  and  Gvnecologic  Nursing,  6 

Griffith— The  Care  of  the  Baby 7 

Hart — Diet  in  Sickness  and  in  Health,   .    .  7 
Meigs — Feeding  in  Early  Infancy,  . 
Morten — Nurses'  Dictionary,    .    .    . 
Stoney — Materia  Medica  for  Nurses, 

Stoney — Practical  Points  in  Nursing,  ...  13 

Stoney — Surgical  Technic  for  Nurses,    .    .  13 

Watson — Handbook  for  Nurses 14 

OBSTETRICS. 
An  American  Text-Book  of  Obstetrics, 
Ashton^Essentials  of  Obstetrics, 
Boisliniere — Obstetric  Accidents 
Borland — Modern  Obstetrics,  . 
Birst — Text-Book  of  Obstetrics, 
Norris — Syllabus  of  Obstetrics,   . 
Schaeffer  and  Edgar — Atlas  of  Obstetri 
cal  Diagnosis  and  Treatment 


17 


PATHOLOGY. 
An  American  Test-Book  of  Pathology-,    .     2 
Diirck  and  Hektoen — Atlas  of  Pathologic 

Histology" 16 

Kalteyer — Essentials  of  Pathology,    . '  .    .    15 
Mallory  and  Wright — Pathological  Tech- 
nique  9 

Senn — Pathology  and  Surgical  Treatment 

of  Tumors, 12 

Stengel — Text-Book  of  Pathology,     ...    12 
Warren — Surgical  Pathology  and  Thera- 
peutics  14 

PHYSIOLOGY. 
An  American  Text-Book  of  Physiology,     2 
Budgett — Essentials  of   Physiology,    ...  15 
Raymond — Text-Book  of  Physiology,  .    .    11 
Stewart—  Manual  of  Physiology,    ....    13 

PRACTICE  OF  MEDICINE. 
An  American  Year-Book  of  Medicine  and 

Surgery 3 

Anders — Practice  of    IMedicine, 4 

Eichhorst — Practice  of  ^Medicine 6 

Lockwood — Manual    of    the    Practice    of 

Medicine 9 

Morris — Ess.  of  Practice  of  Medicine,  .    .    15 
Salinger  and  Kalteyer — Modern   Medi- 
cine  II 

Stevens — Manual  of  Practice  of  Medicine,    13 


SKIN  AND  VENEREAL. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases 2 

Hyde  and  Montgomery — Syphilis  and  the 
Venereal   Diseases, 8 

Martin —  Essentials  of  Minor  Surgery, 
Bandaging,  and  Venereal  Diseases,     .    .    15 

Mr acek  and  Stel wagon — Atlas  of  Diseases 
of  the  Skm 16 

Stelwagon — Essentials  of  Diseases  of  the 
Skin 15 

SURGERY. 

An  American  Text-Book  of  Surgery,  .  .  2 
An  American  Year-Book  of  Medicine  and 

Surgery 3 

Beck — Fractures, 4 

Beck — Manual  of  Surgical  Asepsis,    ...  4 

Da  Costa — Manual  of  Surgery, 5 

International  Text-Book  of  Surgery,  .    .  8 

Keen — Operation  Blank 8 

Keen — The    Surgical    Complications   and 

Sequels  of  Typhoid  Fever 8 

Macdonald — Surgical  Diagnosis  and  Treat- 
ment,    9 

Martin —  Essentials    of    Minor    Surgery, 

Bandaging,  and  Venereal  Diseases,      .    .  15 

Martin— Essentials  of  Surgery, 15 

Moore — Orthopedic  Surgery 10 

Nancrede— Principles  of  Surgery 10 

Pye — Bandaging  and  Surgical  Dressing,     .  11 

Scudder — Treatment  of  Fractures,     ...  12 

Senn — Genito-Urinary  Tuberculosis,  ...  12 

Senn — Practical  Surgery, 12 

Senn — Syllabus  of  Surgery 12 

Senn — Pathology  and  Surgical  Treatment 

of  Tumors, 12 

Warren — Surgical  Pathology  and  Thera- 
peutics   14 

Zuckerkandl  and   Da   Costa — Atlas    of 

Operative  Surgery, 16 

URINE  AND  URINARY  DISEASES. 

Ogden — Clinical  Examination  of  the  Urine,    10 
Saundhy — Renal  and  Urinary  Diseases,    .    11 
Wolff—  Handbook     of      Urine-Examina- 
tion  22 

Wolflf —  Essentials      of     Examination     of 
Urine 15 

MISCELLANEOUS. 

Bastin— Laboratory  Exercises  in  Botany,  .     4 
Golebiewski  and  Bailey — Atlas  of  Dis- 
eases Caused  by  Accidents, 17 

Gould  and  Pyle — Anomalies  and  Curiosi- 
ties of  Medicine 7 

Grafstrom — Massage 7 

Keating — How  to  Examine  for  Life  Insur- 
ance,          8 

Saunders'  Medical  Hand-Atlases,  .  .  16,17 
Saunders'  Pocket  Medical  Formulary,  .  .  11 
Saunders'  Question-Compends,  .  .  .  14,15 
Stewart    and    Lawrence — Essentials    of 

Medical  Electricity 15 

Thornton — Dose-Book    and    Manual    of 

Prescription-Writing 13 

Van  Valzah  and  Nisbet— Diseases  of  the 
Stomach 13 


THE  LATEST  BOOKS. 


Bergey's  Principles  of  Hygiene. 

The  Principles  of  Hygiene :  A  Practical  Manual  for  Students, 
Physicians,  and  Health  Officers.  By  D.  H.  Bergey,  A.  M.,  M.  D., 
First  Assistant,  Laboratory  of  Hygiene,  University  of  Pennsyl- 
vania,     Handsome  octavo  volume  of  about  500  pages,  illustrated. 

Brower*s  Manual  of  Insanity. 

A  Practical  Manual  of  Insanity.  By  Daniel  R.  Brower,  M.  D., 
Professor  of  Nervous  and  Mental  Diseases,  Rush  Medical  College, 
Chicago.      i2mo  volume  of  425  pages,  illustrated. 

Gorham's  Bacteriology. 

A  Laboratory  Course  in  Bacteriology.  By  F.  P.  Gorham,  M.  A., 
Assistant  Professor  in  Biology,  Brown  University.  i2mo  volume 
of  about  160  pages,  handsomely  illustrated. 

Gradle  on  the  Nose,  Throat,  and  Ear. 

Diseases  of  the  Xose,  Throat,  and  Ear.  By  Henry  Gradle, 
M.  D.,  Professor  of  Ophthalmology  and  Otology,  Northwestern 
University  Medical  School,  Chicago.  Handsome  octavo  volume 
of  800  pages,  profusely  illustrated. 

Sollmann*s  Pharmacology. 

A  Text-Book  of  Pharmacology.  By  Torald  Sollmanx,  M.  D., 
Lecturer  on  Pharmacology,  Western  Reserve  University,  Cle\'e- 
land,  Ohio.      Royal  octavo  volume  of  about  700  pages. 

Wolfs  Examination  of   Urine. 

A  Handbook  of  Physiologic  Chemistry  and  Urine  Examination. 
By  Chas.  G.  L.  Wolf,  M.D.,  In.structor  in  Physiologic  Chemistry, 
Cornell  University  Medical  College.  i2mo  volume  of  about  160 
pages. 


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